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The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (2012)

Chapter: 2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions

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Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

2

Assessing the Service Needs of
Older Adults with Mental Health
and Substance Use Conditions

Abstract: This chapter analyzes the available information about the prevalence of mental health and substance use (MH/SU) conditions in older adults and identifies the additional information required to plan for a workforce capable of meeting their current and future service needs. The committee estimates that in 2010, at least 5.6 to 8 million older adults had one or more MH/SU conditions. Several million more older adults were probably also affected, but the available data are not adequate to estimate the number. By 2030, expected growth in the older population will increase the number of older people with MH/SU conditions by 80 percent. Many older adults with MH/SU conditions also have physical health conditions and cognitive, functional, and sensory impairments that can complicate the detection, diagnosis, and treatment of their MH/SU conditions and create difficult caregiving situations for their families and professional and other service providers. In 2010, MH/SU conditions were the eighth most costly type of health care conditions for older adults in the United States, but most older adults with these conditions still do not receive the MH/SU services they need.

An in-depth understanding of the service needs of a target population is integral to analyzing the requirements for a workforce capable of meeting those needs. Thus, the objectives of this chapter are twofold:

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

first, to describe what is known about the prevalence of mental health and substance use (MH/SU) conditions in older adults and their related service needs, and second, to consider the impact of population trends, particularly the aging of the baby boomer cohort and growing population diversity, on the makeup of the older population and future needs for MH/SU services.

The first two sections of the chapter describe the MH/SU conditions that occur in older adults and present the best available information about the proportion and number of older adults that have one or more of the conditions. The third section provides information about prevalence rates for important subgroups of the older population, including racial and ethnic groups and veterans. Later sections describe the coexisting physical health conditions and cognitive and functional impairments that shape the MH/SU service needs of older adults; review the impact of MH/SU conditions; and discuss the available data on use of MH/SU services by older adults and factors that could affect their future MH/SU service needs. The last section summarizes the chapter findings about the current and future MH/SU service needs of the older population. Unfortunately, much of the information required to analyze their MH/SU service needs and plan for a workforce capable of meeting those needs is not available. Additional information needed for these purposes is discussed.

MH/SU CONDITIONS IN OLDER ADULTS

The Institute of Medicine committee identified 27 MH/SU conditions for attention in this report because of their importance in older adults and their implications for service needs and workforce requirements. Fifteen of the conditions, including two substance use conditions, are defined by explicit criteria in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) (APA, 2000), the accepted source for diagnostic classification of MH/SU conditions in the United States. These conditions are referred to as mental disorders in this report. The other 12 conditions are symptoms or clusters of symptoms not classified as mental disorders in DSM-IV-TR. These conditions are referred to as other MH/SU conditions in the report.

Two of the 15 DSM-IV-TR mental disorders, bipolar disorder and schizophrenia, constitute the core of a category of mental health conditions usually referred to as serious mental illness (SMI). SMI is often defined to include severe forms of other DSM-IV-TR mental disorders, such as major depression, but it does not include substance use conditions.

Box 2-1 describes each of the 27 MH/SU conditions identified by the committee, focusing primarily on symptoms. Descriptions of the 15 DSM-IV-TR mental disorders are taken from the DSM-IV-TR manual. Descriptions

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

of the 12 other MH/SU conditions are compiled from published reports. As discussed later in the chapter, substantial numbers of older adults have more than one of the 27 conditions.

The DSM-IV-TR does not provide diagnostic criteria specifically for older adults, and clinicians and researchers have noted that some of the criteria for DSM-IV-TR mental disorders include symptoms that are expressed less often in older adults than younger people with the conditions. Several studies have shown, for example, that older adults with DSM-IV-TR depressive disorders are significantly less likely than younger people with these disorders to exhibit the depressed mood and sadness that are the first listed criteria for the disorders (Gallo et al., 1994, 1999). Likewise, older adults with bipolar disorder are somewhat less likely to exhibit the manic symptoms that are required criteria for the disorder (Coryell et al., 2009; Depp and Jeste, 2004; Hirschfeld and Vornik, 2004).

Diagnostic criteria for DSM mental disorders are established with the publication of the most recent version of the manual, but clinicians, researchers, and others continue to debate the criteria for existing disorders and whether additional MH/SU conditions should be included as disorders in the next version of the manual. The forthcoming DSM-5, scheduled for publication in 2013, will include criteria for diagnosing some new mental disorders, eliminate some disorders, and revise the criteria for many other disorders. It is likely, for example, that hoarding, one of the other MH/SU conditions identified by the IOM committee as important for older adults, will be included as a mental disorder in the DSM-5 (APA, 2010). Thus, the designation of which MH/SU conditions are defined as DSM mental disorders, although set for years at a time, is also changeable.

The committee’s decision to identify both DSM-IV-TR mental disorders and other MH/SU conditions for special attention in this report reflects the report’s focus on the service needs of older adults and workforce requirements and competencies to meet those needs. As described in Box 2-1, both DSM-IV-TR mental disorders and other MH/SU conditions result in significant emotional distress, functional disability, and reduced quality of life for the person. In addition, at least four types of age-related factors can cause, complicate, and exacerbate MH/SU conditions. The four factors are physiological effects of normal aging; changes in life circumstances that frequently occur in old age; coexisting physical health conditions that are common in older adults; and cognitive, functional, and sensory impairments that affect substantial numbers of older adults, especially those age 75 and older. In the presence of these age-related factors, MH/SU conditions that do not meet the criteria for a DSM-IV-TR mental disorder can result in pressing and sustained needs for MH/SU services.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-1
Symptoms of MH/SU Conditions Identified as
Important for Older Adults

DSM-IV-TR Category Depressive Disorders

1.   Major Depressive Disorder is a DSM-IV-TR mental disorder characterized by one or more Major Depressive Episodes. Major Depressive Disorder and Major Depressive Episode (described below) are often referred to as major depression.

2.   Major Depressive Episode is a period of at least 2 weeks in which the person has five or more of nine symptoms nearly every day, including at least one of the first two: (1) depressed mood that lasts most of the day, as indicated by either subjective report (e.g., the person feels sad or empty) or observations of others (e.g., the person appears tearful); or (2) markedly diminished interest or pleasure in all or nearly all activities that lasts most of the day. The seven additional symptoms are (3) significant weight loss when not dieting, weight gain, or decrease or increase in appetite; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate, or indecisiveness; and (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, a suicide plan, or a suicide attempt (APA, 2000).

3.   Dysthymic Disorder is a DSM-IV-TR mental disorder characterized by at least 2 years of depressed mood that lasts most of the day for more days than not, accompanied by at least two of the following additional symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. In the 2-year period, any symptom-free intervals must last no longer than 2 months (APA, 2000).

DSM-IV-TR Bipolar Disorders

4.   DSM-IV-TR Bipolar Disorders I and II. Bipolar I Disorder is a mental disorder characterized by one or more Manic Episodes or Mixed Episodes (described below), often accompanied by a history of major depressive episodes (APA, 2000). Bipolar II Disorder is a mental disorder characterized by one or more major depressive episodes accompanied by at least one Hypomanic

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Episode (APA, 2000). Bipolar I and II disorders are usually referred to as bipolar disorder.

A Manic Episode is a period of at least 1 week in which the person has an abnormally and persistently elevated, expansive, or irritable mood. The mood disturbance must be accompanied by at least three of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressured speech, flight of ideas, distractibility, increased goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful outcomes (e.g., buying sprees, sexual indiscretions, or foolish business investments) (APA, 2000).

A Mixed Episode is a period of at least 1 week in which the criteria for both a manic episode and a major depressive episode are met nearly every day. The person has rapidly alternating moods (sadness, irritability, euphoria) often accompanied by agitation, insomnia, appetite dysregulation, psychosis, and suicidal thinking (APA, 2000).

DSM-IV-TR Anxiety Disorders

5.   Panic Disorder is a DSM-IV-TR mental disorder characterized by recurrent unexpected panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the consequences of an attack, or a significant change in behavior to avoid panic attacks. A panic attack is a discrete period in which the person experiences sudden intense apprehension, fear, or terror in the absence of real danger. It must be accompanied by at least 4 of 13 additional symptoms: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feelings of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded or faint; feelings of unreality or being detached from oneself; fear of losing control or going crazy; fear of dying; numbness or tingling sensations; and chills or hot flashes. Panic disorder can occur with or without agoraphobia (APA, 2000).

6.   Agoraphobia Without Panic is a DSM-IV-TR mental disorder characterized by anxiety about, or avoidance of, places or situations in which escape might be difficult or embarrassing or help might not be available in the event of a panic attack or panic-like symptoms. The person must not have a history of panic attacks.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Agoraphobic fears typically involve specific situations, such as being outside the home alone; being in a crowd; standing in a line; being on a bridge; or traveling in a bus, train, or car (APA, 2000).

7.   Social Phobia is a DSM-IV-TR mental disorder characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations in which embarrassment may occur. The person usually tries to avoid the feared situation. The fear and/or avoidance must interfere significantly with the person’s normal routine, occupational functioning, or social activities or relationships (APA, 2000).

8.   Obsessive-Compulsive Disorder is a DSM-IV-TR mental disorder characterized by recurrent obsessions and/or compulsions. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause anxiety or distress. Examples are repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery. Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., counting and repeating words silently), the goal of which is to prevent or reduce anxiety or distress. The compulsion is usually intended to reduce distress related to the obsession or to prevent a dreaded event or situation (APA, 2000).

9.   Generalized Anxiety Disorder is a DSM-IV-TR mental disorder characterized by persistent, excessive anxiety and worry that occurs most days for at least 6 months. The intensity, duration, or frequency of these symptoms is far out of proportion to the likelihood or impact of the feared event. The symptoms are accompanied by at least three of six additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep. The person may not realize the anxiety and worry are excessive but is distressed by constant worry, difficulty controlling the worry, and related impairments in important areas of functioning (APA, 2000).

10.   Posttraumatic Stress Disorder (PTSD) is a DSM-IV-TR mental disorder characterized by symptoms that develop after exposure to an extremely traumatic event involving either (1) direct personal experience of threatened death, serious injury, or other threat

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

to one’s physical integrity; or (2) witnessing an event involving death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury to a family member or other close associate. The person’s response to the event must involve intense fear, helplessness, or horror, and the symptoms must last more than 1 month and include persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent arousal (e.g., rapid heart rate). Traumatic events experienced directly include military combat, violent personal assault, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or diagnosis of a life-threatening illness. The disorder may be especially severe or long-lasting when the stressor is of human design (e.g., torture or rape) (APA, 2000).

DSM-IV-TR Schizophrenia and Other Psychotic Disorders

11.   Schizophrenia is a DSM-IV-TR mental disorder that lasts for at least 6 months, including at least 1 month during which the person has two or more of the following: positive symptoms (delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior), and/or negative symptoms (restrictions in the range and intensity of emotional expression, the fluency and productivity of thought and speech, and the initiation of goaldirected behavior). For a significant portion of the time after onset of the disorder, the person’s functioning in one or more major areas, such as work, interpersonal relations, and self-care, must be markedly below his or her prior functioning (APA, 2000).

In 2000, an international panel recommended two new classifications: late-onset schizophrenia, with onset after age 45, and very-late-onset schizophrenia, with onset after age 60 (Howard et al., 2000). DSM-IV-TR criteria do not list these classifications, but the DSM-IV-TR manual discusses late-onset schizophrenia (APA, 2000), and a late-onset specification code can be added to identify the conditions.

DSM-IV-TR Substance-Related Disorders Substance Dependence and Substance Abuse are defined similarly for alcohol and other substances (described below). A person with a DSM-IV-TR diagnosis of

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Substance Dependence cannot also have a DSM-IV-TR diagnosis of Substance Abuse.

12.   Alcohol Dependence and Alcohol Abuse are DSM-IV-TR mental disorders that meet the requirements for substance dependence and abuse defined with respect to alcohol.

13.   Drug Dependence and Drug Abuse are DSM-IV-TR mental disorders that meet the requirements for substance dependence and abuse defined with respect to illicit drugs and prescribed or over-the-counter drugs used for nonmedical purposes, including amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, sedatives, hypnotics, and antianxiety drugs (APA, 2000).

Substance Dependence is a cluster of symptoms indicating the person continues to use the substance despite significant substance-related impairment or distress. The pattern of repeated self-administration must result in three or more of seven symptoms in three categories: tolerance, withdrawal, and compulsive drug-taking behavior (APA, 2000).

Substance Abuse is a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period: (1) failure to fulfill major role obligations; (2) recurrent substance use in situations in which it is physically hazardous; (3) recurrent substance-related legal problems; and (4) continued use despite recurrent social or interpersonal problems caused or exacerbated by the substance use (APA, 2000).

DSM-IV-TR Adjustment Disorders

14.   Adjustment Disorder is a DSM-IV-TR mental disorder characterized by a psychological or behavioral response to an identifiable stressor that results in clinically significant emotional or behavioral symptoms. The symptoms must occur within 3 months of the onset of the stressor and resolve within 6 months after the stressor is resolved. The person must have marked distress that is in excess of what would be expected given the nature of the stressor or significant impairment in social or occupational functioning (APA, 2000).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

DSM-IV-TR Personality Disorders

15.   Personality Disorders are DSM-IV-TR mental disorders characterized by an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the person’s culture, is pervasive and inflexible, and leads to distress or impairment. The onset of the disorder can be traced back to adolescence or early adulthood. The 10 personality disorders are paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorder (APA, 2000).

MH/SU Conditions That Are Not DSM-IV-TR Disorders

16.   Depressive Symptoms is a term to describe symptoms, such as depressed mood and feelings of worthlessness and guilt, that do not meet the criteria for a diagnosis of a DSM-IV-TR depressive disorder, usually because of insufficient duration, number, or severity. Other terms for such symptoms are subsyndromal depression, subthreshold depression, subclinical depression, and minor depression (Blazer, 2003; Lavretsky and Kumar, 2002; Lyness et al., 2009).

17.   Anxiety Symptoms is a term to describe symptoms, such as excessive nervousness, worry, and fear or avoidance of anxietycausing situations that do not meet the criteria for a DSM-IV-TR diagnosis of an anxiety disorder, usually because of insufficient number or severity. Other terms for such symptoms are subsyndromal anxiety and subthreshold anxiety (Grenier et al., 2011; Lenze and Wetherell, 2011).

18.   At-Risk Drinking is a term to describe alcohol-related symptoms that do not meet the criteria for a DSM-IV-TR diagnosis of alcohol dependence or abuse, usually because of insufficient number or severity. Symptoms of at-risk drinking include having more than a specified number of drinks (usually 2 per day); binge drinking, and exhibiting any of the symptoms of alcohol dependence or abuse (e.g., tolerance, withdrawal, compulsive alcohol use behaviors, failure to fulfill major role obligations, and recurrent alcohol-related legal, social, or interpersonal problems). Other terms for such symptoms are subsyndromal alcohol dependence, subthreshold alcohol dependence, alcohol misuse, and problem

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

drinking (APA, 2000; Berks and McCormick, 2008; Blazer and Wu, 2009a, 2011; Blow and Barry, 2002; Merrick et al., 2008).

19.   At-Risk Drug Use is a term to describe drug-related symptoms that do not meet the criteria for a DSM-IV-TR diagnosis of drug dependence or abuse, usually because of insufficient number or severity. Symptoms of at-risk drug use include drug overdoses and any of the symptoms of drug dependence and abuse (e.g., tolerance, withdrawal, compulsive drug use behaviors, failure to fulfill major role obligations, and recurrent drug-related legal, social, or interpersonal problems). Other terms for such symptoms are subthreshold drug dependence, at-risk use of psychoactive drugs, and extra-medical drug use (Blazer and Wu, 2009b,c; Degenhardt et al., 2007; Wu and Blazer, 2011).

20.   Suicidal Ideation is a term to describe serious thoughts about suicide and death. It is sometimes subdivided into active suicidal ideation (e.g., thinking about taking one’s own life) and passive suicidal ideation or passive death ideation (e.g., feeling that life is not worth living and wishing one were dead) (Bartels et al., 2002; Beck et al., 1979; Paykel et al., 1974; Raue et al., 2007).

21.   Suicide Plans and Attempts are terms to describe plans and behaviors to kill oneself. Suicide plans can include selecting a time when one will be alone and therefore able to kill oneself, selecting a means for killing oneself, and obtaining the means for killing oneself. Suicide attempts are active behaviors to end one’s life.

Suicidal ideation, suicide plans, and suicide attempts are included as one of the nine symptoms of a DSM-IV-TR major depressive episode (APA, 2000).

22.   Behavioral and Psychiatric Symptoms Associated with Dementia is a term to describe noncognitive symptoms of diseases and conditions that cause dementia. Such symptoms include delusions, hallucinations, agitation, verbal aggression; physical aggression, anxiety, apathy, depression, dysphoria, irritability, elation, euphoria, aberrant motor behavior, appetite and eating disorders, sleep disorders; inappropriate sexual behavior; and unsafe wandering. Other terms for such symptoms are neuropsychiatric symptoms of dementia and behavioral and psychological symptoms of dementia (Chan et al., 2003; Cohen-Mansfield et al., 1989; Cummings et al., 1994; Jeste and Finkel, 2000; Lyketsos

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

et al., 2000; McNeese et al., 2009; Smith and Buckwalter, 2005; Teri et al., 1992).

DSM-IV-TR defines diagnostic criteria for several dementiarelated mental disorders, and coding specifications for behavioral and psychiatric symptoms can be added to these disorders, but behavioral and psychiatric symptoms associated with dementia are not classified as DSM-IV-TR mental disorders.

23.   Hoarding is a term to describe symptoms, such as the accumulation of a large volume of paper, newspapers, containers, food, books, trash, and other materials that clutter living areas to the extent that they cannot be used for their intended purposes. Severe hoarding can create health and safety hazards for the person and others living in the same home, building, or community. The person is often unaware of the problem, but it may result in a referral or complaint to a public health, adult protective services, or case management agency. Another term for these symptoms is compulsive hoarding (Ayers et al., 2010; Frost et al., 2000; Kim et al., 2001; Pertusa et al., 2008).

24.   Severe Domestic Squalor is a term to describe a living situation, often from the perspective of a public health or adult protective services worker who is responding to a referral or complaint. The living situation is said to be filthy; cluttered with dirt, garbage, and rubbish; and infested with vermin, excrement, and decomposing food. Visitors experience disgust and revulsion, and the smell is sometimes said to be unbearable to all except the occupant, who often refuses help to clean the living situation (Snowdon and Halliday, 2011; Snowdon et al., 2007).

25.   Severe Self-Neglect is a term used to describe health-related symptoms, such as malnutrition, dehydration, untreated medical conditions, and hazardous living conditions, that result from a person’s failure to provide for his or her own needs. The National Center on Elder Abuse says that self-neglect “generally manifests itself in an older person as a refusal or failure to provide himself/ herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions” (NCEA, 2011). Severity of self-neglect is usually defined in the domains of personal hygiene, cleanliness, health needs, household and environmental hazards, and home safety (Dong et al., 2010; Kelly et al., 2008).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

The DSM-IV-TR category Problems Related to Abuse or Neglect includes seven mental disorders related to abuse and neglect, but not self-neglect (APA, 2000).

26.   Fear of Falling is a term used to describe persistent, often exaggerated, concerns about falling that occur in adults who have or have not fallen. The symptoms can result in loss of confidence in ability to perform daily activities, activity restriction, changes in posture and gait, future falls, avoidance of feared activities and environments, loss of mobility, and loss of independence (Delbaere et al., 2010; Jorstad et al., 2005; Murphy et al., 2003; Oh-Park et al., 2011; Yardley and Smith, 2002).

The following examples illustrate the impact of interactions among the four age-related factors noted earlier and MH/SU conditions in older adults:

1.   Age-related changes in the metabolism of alcohol and drugs, including prescription drugs, can cause or exacerbate DSM-IV-TR and other alcohol and drug use conditions and increase an older person’s risk of dangerous overdoses. This can happen even to people who have used alcohol and drugs at the same dose and frequency for many years without serious negative effects (Blow and Barry, 2002; Dowling et al., 2008; Wu and Blazer, 2011).

2.   Losses that occur frequently in old age, such as the death of a spouse, partner, close relative, or friend, can trigger emotional responses that cause or exacerbate DSM-IV-TR depressive disorders and depressive symptoms (Alexopoulos, 2005; Zisook and Shuchter, 1991) and lead to severe, debilitating symptoms, such as those seen in complicated grief (Kersting et al., 2011). In a person with significant loss, differentiating major depression and grief is often difficult.

3.   Acute and chronic physical health conditions that are common in older adults and medications to treat the conditions can cause and exacerbate DSM-IV-TR mental disorders and other MH/SU conditions and worsen their impact on the person (Blow and Barry, 2002; Jeste et al., 2005; Schultz, 2011).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

27.   Complicated Grief is a term used to describe symptoms associated with bereavement that are intense and go beyond the usual and culturally expected response to a death. These symptoms include disbelief and/or anger and bitterness about the death; severe, recurrent, and painful feelings of intense longing for the deceased; preoccupation with thoughts of the deceased, often involving intrusive images and thoughts; avoidance of situations and activities that remind one of the death; and neglect of necessary adaptive activities (Horowitz et al., 1997; Shear et al., 2005).

4.   Cognitive, functional, and sensory impairments can complicate the detection and diagnosis of DSM-IV-TR mental disorders and other MH/SU conditions and reduce an older person’s ability to comply with recommended treatments, including health-related behaviors and medications prescribed for the person’s MH/SU and physical health conditions (Cohen, 1996; Schultz, 2011; Wolitzky-Taylor et al., 2010).

The complex interactions among MH/SU conditions and these age-related factors, especially coexisting physical health conditions and cognitive, functional, and sensory impairments, have been described by many geriatric mental health professionals and researchers as a key or defining characteristic of the field (Alexopoulos, 2005; Blazer et al., 2004; Borson et al., 2001; Bruce et al., 1994; Bryant et al., 2009; Cohen, 1996; Flint, 2002; Katz, 1996; Knight, 2004; Lyness et al., 2006; Reynolds et al., 2002). The adverse consequences of these interactions work both ways (Bryant et al., 2009; Wolitzky-Taylor et al., 2010). In the case of an older person with depression, for example, physical health conditions and cognitive and functional impairments can worsen the person’s depression and, conversely, depression can worsen the person’s physical health and cognitive and functional impairments (Blazer, 2003).

People of any age can experience physiological changes, losses, physical health conditions and cognitive, functional, and sensory impairments

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

that may cause, complicate, and exacerbate MH/SU conditions. These factors are, however, more prominent and pervasive in older people (Bartels, 2004; Kilbourne et al., 2005).

At worst, interactions among mental disorders, other MH/SU conditions, and age-related factors can result in what has been described as a “spiral” or “cascade” of decline in physical, cognitive, and psychological health (Blazer, 2000; Bruce et al., 1994; Bryant et al., 2008). In such situations, even a highly skilled clinician can have difficulty disentangling the components of the problem and deciding what to do first to reverse the decline.

Because of their coexisting physical health conditions, older adults with MH/SU conditions are frequently seen in medical care settings, such as primary care offices, hospitals, and emergency departments. Likewise, because of their coexisting physical health conditions and cognitive and functional impairments, older adults with MH/SU conditions may be receiving nursing and nonmedical personal care services at home or in a residential care setting, such as a nursing home or assisted living facility. In all these settings, the interactions of MH/SU conditions and age-related physiological changes, losses, physical health conditions, and cognitive and functional impairments can create difficult caregiving situations. Health care professionals and service providers who work with older adults at home or in general medical care, nursing home, and other residential care settings may not expect or recognize the MH/SU conditions, understand their implications for the person’s physical health and cognitive and functional status, or know how to respond.

In the same way, specialty MH/SU service providers, especially those who do not have geriatric training, may not recognize physical health conditions or cognitive, functional, or sensory impairments in the older adults for whom they provide services. They may not understand the complex interactions among these coexisting conditions and the person’s MH/SU condition or know how to adapt usual treatments and services to accommodate the coexisting conditions. As a result, treatable physical health conditions may not be treated, and medications that can seriously worsen the person’s physical health and cognitive and functional status may be unknowingly prescribed (Druss and Walker, 2011).

PREVALENCE OF MH/SU CONDITIONS IN OLDER ADULTS

To analyze the service needs of older adults with DSM-IV-TR mental disorders and other MH/SU conditions and then plan for the workforce required to meet the needs, it is necessary to know how many older adults have the conditions. As noted earlier, some older adults have more than one MH/SU condition. For planning purposes, it is necessary

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

to know how many people have each condition, for example, how many have depressive disorders and how many have alcohol dependence or abuse, as well as how many have two or more conditions, for example, how many have both depressive disorders and alcohol dependence or abuse. The latter information is required to determine the total number of people who need MH/SU services, whether for only one or more than one condition.

To estimate the number of older adults who have any of the 27 MH/SU conditions identified by the committee and how many have more than one such condition, the committee gathered available information from published research conducted in population-based samples in the United States. To fill gaps, unpublished data were obtained whenever possible, but many gaps remain.

To ensure that all older adults with MH/SU conditions were included in its estimates and, at the same time, avoid double counting, the committee used a U.S. Census Bureau classification system that divides the population into two categories: (1) people living in housing units, including houses, apartments, mobile homes, and single rooms occupied as separate living quarters, and (2) people living in group quarters, including nursing homes, prisons and jails, psychiatric hospitals, residential treatment centers, and homeless shelters (Census Bureau, 2010a). People categorized as living in housing units are referred to in this report as people living in the community or community-living people.

The 2010 Census found there were 40.3 million adults age 65 and older in the United States (Census Bureau, 2011a). Of the 40.3 million older adults, about 38.8 million (96 percent) were living in the community, and 1.5 million (4 percent) were living in group quarters settings (Census Bureau, 2010b). These U.S. Census figures are used in this section to develop population estimates of the number of older adults who had each of the identified MH/SU conditions and the number who had one or more of the conditions in 2010.

Some older adults with MH/SU conditions developed the conditions after age 65, and some grew older with conditions they had for many years. Both groups are included in the estimates presented in this section. Likewise, many older adults have MH/SU conditions that have not been recognized, and as a result, they do not have formal diagnoses of the conditions. The information presented in this section does not rely on formal diagnoses, and the estimates provided in the section include people with diagnosed and undiagnosed conditions.

The U.S. Census Bureau classification system used by the committee categorizes people who live in assisted living, senior housing, and other public housing facilities as people living in the community and does not distinguish them from people who live in single-family housing.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Although use of this classification system is important for placing the committee’s estimates in the context of U.S. Census figures for the number of older adults in the country and avoiding double counting, classifying people who live in assisted living, senior housing, and other public housing facilities in a different category from people living in nursing homes is not ideal for characterizing MH/SU conditions in older adults. In fact, the proportion of older adults in these non–nursing home, residential facilities who have MH/SU conditions is closer to the proportion of nursing home residents with the conditions than it is to the proportion of other community-living older adults with the conditions (Gruber-Baldini et al., 2004; Rabins et al., 1996; Rosenblatt et al., 2004; Watson et al., 2003). Available information about the proportions of assisted living, senior housing, and public housing facility residents that have MH/SU conditions and implications for their service needs and related workforce requirements are discussed later in the chapter. For purposes of estimating the proportion and number of older adults with MH/SU conditions, however, residents of non–nursing home, residential facilities are included with other community-living older adults in this section.

In the following discussion, available information about the proportion and number of older adults that have particular MS/SU conditions identified by the committee is presented in four tables. Particular conditions are included in each table based on two factors: (1) whether the available information about the particular MH/SU condition pertains to older people who live in the community (Tables 2-1 and 2-2), in group quarters settings (Table 2-4), or both (Table 2-3); and (2) whether the available information about the prevalence of the particular MH/SU condition can be combined with prevalence information for other MH/SU conditions without double counting (Tables 2-1, 2-3, and 2-4) or not (Table 2-2). Table 2-5 shows the totals for the proportion and number of older adults who had MH/SU conditions for which adequate data are available.

Prevalence of MH/SU Conditions in Community-Living Older Adults

Information about the prevalence of some of the 27 identified conditions in community-living older adults is available from large-scale surveys of MH/SU conditions that have been conducted in nationally representative, population-based samples in the United States (see Box 2-2). These surveys used structured interviews based primarily on DSM-IV-TR diagnostic criteria to identify people with particular MH/SU conditions. The exact wording and number of questions about each condition and the decision rules used to identify people who do or do not have the condition vary from one survey to another, and most of the surveys were conducted a decade ago. Despite these caveats, the surveys provide useful

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-2
Selected Population-Based Surveys of Mental Health and
Substance Use Conditions in Nationally Representative
Samples of Community-Living Adults in the United States

Collaborative Psychiatric Epidemiological Studies (CPES). The CPES is a group of three related surveys (below) funded by the National Institute of Mental Health. The three surveys were conducted independently, but used a common sampling process that allows for analyses of pooled data as if they were from a single, nationally representative sample (Heeringa et al., 2004). The samples included people living in the community and excluded people living in prisons, jails, nursing homes, and long-term medical or dependent care facilities, and military personnel living on a military base. The surveys used a structured interview, a modified version of the World Mental Health Composite International Diagnostic Interview (Kessler and Ustun, 2004), administered in person by a research interviewer. The combined sample for the three surveys was 20,013 people, including 2,584 adults age 65 and older.

•   National Comorbidity Survey-Replication (NCS-R). The NCS-R was conducted from 2001 to 2002 in a sample of 9,282 English-speaking people, including 1,461 adults age 65 and older.

•   National Latino and Asian American Study (NLAAS). The NLAAS was conducted in 2002-2003 in a sample of 4,649 Latinos (i.e., Mexicans, Puerto Ricans, Cubans, and other Latinos) and Asians (i.e., Chinese, Filipinos, Vietnamese, and other Asians), including 701 adults age 65 and older. Ethnicity was self-defined and classified according to U.S. Census categories. Interviews were conducted in English, Spanish, Tagalog, Vietnamese, or Mandarin.

•   National Study of American Life (NSAL). The NSAL was conducted in 2001-2003 in a sample of 6,082 English-speaking African Americans, Afro-Caribbeans, and non-Hispanic whites, including 422 adults age 65 and older.

National Epidemiological Survey of Alcohol and Related Conditions Wave 1 (NESARC 1). The NESARC 1 was funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and conducted from 2001 to 2002 in a sample of 43,093 English-speaking people, including 8,205 adults age 65 and older. The

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

sample included people living in the community and noninstitutional group quarters, such as boarding houses, rooming houses, nontransient hotels, motels, shelters, and group homes; it excluded people in prisons, jails, and nursing homes (Grant and Dawson, 2006). The survey used a structured interview, the “Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV version” (Grant et al., 2001) that was administered in person by a lay interviewer.

National Epidemiological Survey of Alcohol and Related Conditions Wave 2 (NESARC 2). The NESARC 2 was funded by NIAAA and was conducted from 2004 to 2005. The sample included 34,653 of the initial 43,093 NESARC 1 respondents (NIAAA, 2010), including 7,177 adults age 65 and older. Of the 8,440 Wave 1 respondents of all ages who were not interviewed in Wave 2, 3,114 were not eligible because they were institutionalized, mentally or physically impaired, on active duty in the armed forces, deceased, or deported, and 5,306 refused or could not be located. The survey used the same structured interview and in-person administration procedure that was used for the NESARC 1 survey.

National Survey of Drug Use and Health (NSDUH). The NSDUH is funded by the Substance Abuse and Mental Health Services Administration and is conducted annually. The 2010 sample was 68,487 people, including 2,517 adults age 65 and older (CBHSQ, 2011n). The sample includes residents of households and non-institutional group quarters, such as shelters, halfway houses, and rooming houses, and civilians living on military bases, and excludes homeless people who do not use shelters, military personnel on active duty, and residents of prisons, jails, nursing homes, mental institutions, and long-term hospitals. The survey used a structured interview and was conducted in person by a lay interviewer, but most of the questions were administered with a computer-assisted self-interviewing technology to provide a highly confidential mode of response.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

information about the proportion and number of older adults who have the conditions. Data on adults age 65 and older that were not included in published reports from the surveys were generated for the committee by the Center for Multicultural Mental Health Research and the Substance Abuse and Mental Health Services Administration (SAMHSA).

The surveys described in Box 2-2 and some of the other sources used in this section provide information about the proportion of people who had particular MH/SU conditions in the previous month, the previous 12 months, or at any time in the person’s life. For purposes of analyzing current and relatively sustained service needs, the committee decided to use 12-month prevalence rates whenever possible.

Prevalence of 10 MH/SU Conditions in Community-Living Older Adults

Table 2-1 shows 12-month prevalence rates and the estimated number of older adults with any of 10 MH/SU conditions for which data are available from three surveys, the Collaborative Psychiatric Epidemiologic Studies (CPES), National Epidemiological Survey of Alcohol and Related Conditions Wave 1 (NESARC 1), and National Epidemiological Survey of Alcohol and Related Conditions Wave 2 (NESARC 2) (see Box 2-2). The 10 conditions are all DSM-IV-TR mental disorders. The middle column shows the range of rates from the three surveys for each condition, one or more conditions, only one, two or more, and three or more conditions. The third column shows the range of estimates for the number of adults age 65 and older who had the condition(s) in 2010, calculated by multiplying the rates in the middle column by 38.8 million, the 2010 Census figure for the number of community-living adults age 65 and older.

As shown in Table 2-1, 6.8 to 10.2 percent of community-living adults age 65 and older had one or more of the conditions included in the table. Given the differences in the surveys, this range and the ranges for specific conditions are reassuringly small.

Using the 2010 Census figure for the community-living population age 65 and older, the 6.8 to 10.2 percent range indicates that in 2010, 2.6 million to 4 million community-living older adults had one or more of the 10 MH/SU conditions. Among those people, 800,000 to 900,000 people had two or more conditions, and 200,000 to 300,000 people had three or more conditions.

The conditions with the highest prevalence are depressive disorders, including major depressive episode and dysthymic disorder. In 2010, 3 to 4.5 percent of community-living older adults, about 1.2 million to 1.8 million people, had these conditions. The condition with the next highest prevalence is social phobia, which affected 0.9 to 2.6 percent of community-living older adults, about 400,000 to 1 million people in 2010.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-1
12-Month Prevalence Rates and Estimated Number of Community-Living Adults Age 65 and Older with 10 MH/SU Conditions

Mental Health or Substance Use Condition

Prevalence
Ratea
(%)

Estimated Number of Older Adults in
2010b
(Millions)

Mental health conditions
Depressive disorders

3.0-4.5

1.2-1.8

   Major depressive episode(s)

3.0-4.3

1.2-1.7

   Dysthymic disorder

0.6-1.6

0.2-0.6

Panic disorder

0.8-1.1

0.3-0.4

Agoraphobia without panic

c-0.3

d-0.1

Social phobia

0.9-2.6

0.4-1.0

Generalized anxiety disorder

1.1-2.1

0.4-0.8

Posttraumatic stress disorder (PTSD)c

0.6-2.6

0.2-1.0

Substance use conditions
Alcohol dependence or abuse

d-1.9

e-0.7

Drug dependence or abuse

d-0.2

e-0.1

Summary figures
One or more of the conditions

6.8-10.2

2.6-4.0

One of the conditions

4.8-7.8

1.8-3.0

Two or more of the conditions

2.0-2.4

0.8-0.9

Three or more of the conditions

0.5-0.8

0.2-0.3

aPrevalence rate is the range of rates from the Collaborative Psychiatric Epidemiological Studies (CPES), National Epidemiological Survey of Alcohol and Related Conditions Wave 1 (NESARC 1), and National Epidemiological Survey of Alcohol and Related Conditions Wave 2 (NESARC 2).

bThe estimated number of older adults was calculated by multiplying the prevalence rates (middle column) by 38.8 million.

cThe NESARC 1 survey did not measure PTSD; thus, the figures for PTSD represent data from only two of the surveys, the CPES and NESARC 2.

dThe lowest prevalence rate from the three surveys is less than 0.2 percent.

eThe lowest number of people with the condition from the three surveys is less than 50,000.

SOURCE: Center for Multicultural Mental Health Research, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

The range of rates for alcohol dependence or abuse indicates that up to 700,000 community-living older adults had this condition in 2010. Data from the National Survey on Drug Use and Health (NSDUH) (see Box 2-2) support the high end of the range, showing that 780,000 older adults had alcohol dependence or abuse in 2010 (CBHSQ, 2011m).

The rates for drug dependence or abuse are smaller, up to 0.2 percent of community-living older adults, or about 78,000 people in 2010. The comparable figure from the NSDUH is even smaller, about 22,000 people in 2010 (CBHSQ, 2011m).

Posttraumatic stress disorder (PTSD) had the widest range of rates, 0.6 to 2.6 percent, and number of older adults affected, 200,000 to 1 million (see Box 2-3). PTSD is known to occur in veterans as a result of combat-related trauma. Many other kinds of traumatic events can also lead to PTSD, and available data show that older women, who are rarely veterans, are somewhat more likely than older men to have PTSD (Pietrzak et al., 2012). Moreover, older men, including older veterans who experienced combat-related trauma, can develop PTSD as a result of other traumatic events (Cook et al., 2005; Pietrzak et al., 2012; Schnurr et al., 2002).

For people with preexisting PTSD, various trajectories have been shown to occur with aging, including symptom stability, worsening, improvement, and fluctuation (Lapp et al., 2011). The onset and progression of dementia sometimes can trigger and exacerbate symptoms in older adults with PTSD, resulting in frightening situations for spouses and other family members (Johnston, 2000; Mittal et al., 2001).

Prevalence of Nine Additional MH/SU Conditions in Community-Living Older Adults

In addition to the 10 MH/SU conditions included in Table 2-1, the committee found data to support estimates of the prevalence of 10 of the remaining MH/SU conditions identified as important for older adults. These data come from a wider array of sources, including any one of the surveys shown in Box 2-2; other population-based surveys conducted in community samples using comprehensive, structured interviews; population-based surveys conducted in national samples using only one or a few questions to identify such people; and Medicare claims.

Table 2-2 shows the 12-month prevalence rates and estimated number of older adults who have 9 of the 10 conditions. Rates for the tenth condition, behavioral and psychiatric symptoms associated with dementia, are not included in Table 2-2 because the only available population-based data for this condition come from a survey that included both community-living older adults and nursing home residents, whereas the data for the other nine conditions come from studies that include only community-living

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-3
Posttraumatic Stress Disorder (PTSD) in Older Adults

Data from the National Epidemiological Survey of Alcohol and Related Conditions Wave 2 (NESARC 2) indicate that 2.4 percent of community-living older adults in the United States have PTSD. The 2.4 percent figure represents current prevalence, as assessed at the time of the interview, based on DSM-IV-TR criteria, including the requirement that exposure to the traumatic event must precede development of the condition. The current prevalence of PTSD was higher for people age 65-74 than for those age 75 and older (2.7 percent vs. 2.0 percent, respectively). It was also higher for Hispanic/Latinos age 65 and older (4.3 percent) than for whites (2.3 percent) and African Americans (2.0 percent) in that age group.

NESARC 2 survey data also indicate that current prevalence of PTSD is higher in community-living adults under age 65 than in those age 65 and older. The data show that 4.2 percent of adults age 55-64 had PTSD, compared with 2.4 percent of those age 65 and older. The reasons for this difference are not known, but plausible explanations include cohort effects related to exposure, for example, to military service; earlier mortality in those with PTSD; underreporting of symptoms by older adults; and underrecognition of PTSD symptoms that may manifest differently in older adults (Lapp et al., 2011; Owens et al., 2005; van Zelst et al., 2003a,b).

After exposure to a traumatic event, older and younger adults generally experience similar risk of developing PTSD (Acierno et al., 2002; Chung et al., 2004; Kohn et al., 2005). Factors associated with susceptibility for PTSD are also similar across age groups. These factors include female gender, childhood adversity, low self-efficacy, lack of social support, and personality traits, such as neuroticism (Acierno et al., 2002; Lapp et al., 2011; Ozer et al., 2003; van Zelst et al., 2003b).

In the United States, research on PTSD in older adults has focused most on older combat veterans and prisoners of war (Dirkzwager

older adults. Prevalence rates for behavioral and psychiatric symptoms associated with dementia are discussed later in this section.

The middle column of Table 2-2 shows the prevalence rate or range of rates for each of the nine conditions. The third column shows the figure or range of figures for the number of adults age 65 and older who had the condition in 2010, calculated by multiplying the rate(s) in the

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

et al., 2001; Port et al., 2001). One study found that World War II veterans who experienced moderate-to-heavy combat were 13 times as likely to have PTSD 45 years later compared with noncombat veterans (Spiro et al., 1994).

Some studies have focused on PTSD in Holocaust survivors (Trappler et al., 2007; Yehuda et al., 2009). Other studies have documented PTSD in people exposed to other traumatic life events, such as sexual and criminal assault, disasters, life-threatening illness, accidents (including falls), and unexpected loss of a loved one (Chung et al., 2009; Spitzer et al., 2008).

Comorbid mental health and substance use conditions, including depression, anxiety disorders, and alcohol and drug use disorders, are common in older adults with PTSD (Brady, 1997; Jacobsen et al., 2001; Lapp et al., 2011; Spitzer et al., 2008). High levels of coexisting physical health conditions, especially heart disease and ulcers, are also common in such people (Pietrzak et al., 2012; Schnurr et al., 2000).

Several studies conducted in large samples of veterans have found that veterans with PTSD are twice as likely as those without PTSD to develop dementia (Qureshi et al., 2010; Yaffe et al., 2010). Questions have been raised about the mechanism for this association (Borson, 2010; Pittman, 2010). Despite these questions, numerous case studies have documented that dementia can result in the emergence or exacerbation of PTSD symptoms in some older adults (Cook et al., 2003; Dallam et al., 2011; Johnston, 2000; Mittal et al., 2001; van Achterberg et al., 2001). Older veterans with PTSD and dementia may become extremely agitated, paranoid, and physically combative, occasionally attacking their spouse or, conversely, attempting to protect their spouse from other, imagined attackers.

SOURCE: K. M. Bohnert, Health Services Research and Development Service, Department of Veterans Affairs, Ann Arbor, MI, text provided to the IOM committee, January 10, 2012.

middle column by 38.8 million, the U.S. Census figure for the number of community-living adults age 65 and older in 2010.

The proportions of community-living older adults who have any of the nine conditions included in Table 2-2 range from less than 0.2 percent to 11.1 percent. Because the data come from unrelated studies, it is not possible to determine the proportion that has one or more of the conditions.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-2
12-Month Prevalence Rates and Estimated Number of Adults Age 65 and Older with Nine Additional MH/SU Conditions

Mental Health or Substance Use Condition

Prevalence Ratea (%)

Estimated Number of Older Adults in 2010b (Millions)

Mental health conditions
   Bipolar disorder

c-0.2

d-0.1

   Schizophrenia

0.2-0.8

0.1-0.3

   Obsessive-compulsive disorder

0.8

0.3

   Depressive symptoms

1.1-11.1

0.4-4.3

   Anxiety symptoms

4.3

1.7

   Suicidal ideation

0.5-1.7

0.2-0.7

   Suicide plans and attempts

c

d

Substance use conditions
   At-risk drinking

5.2

2.0

   At-risk drug use

0.9

0.4

aPrevalence rate is the rate or range of rates from the cited sources.

bThe number of people was calculated by multiplying the percentages in the middle column by 38.8 million.

cThe prevalence rate is less than 0.2 percent.

dThe number of people with the condition is less than 50,000.

SOURCES: Blazer and Wu, 2011; Blazer et al., 1987; CBHSQ, 2011i, 2012c; Center for Multicultural Mental Health Research, 2011; Gum et al., 2009; Harris and Cooper, 2006; Hybels et al., 2009; Jeste et al., 1999; Kessler et al., 2005; Steffens et al., 2000; Weissman et al., 1988; Wolitzky-Taylor et al., 2010; Wu et al., 2006.

Three of the MH/SU conditions in Table 2-2 are DSM-IV-TR mental disorders: bipolar disorder, schizophrenia, and obsessive-compulsive disorder (OCD). They are not included in Table 2-1 with other DSM-IV-TR disorders because information about their prevalence is not available from all three surveys used to create Table 2-1. In fact, relatively little information is available about the proportion of community-living older

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

adults who have any of the three disorders. The limited information reflects the difficulty of measuring these disorders in population-based surveys. Some researchers and clinicians question whether the prevalence of mental disorders in general, and the three disorders in particular, is identified accurately by the structured interviews used in the large-scale, population-based surveys conducted to date. For bipolar disorder, schizophrenia, and OCD, they question whether the surveys have found and interviewed representative samples of older adults with the disorders and whether valid prevalence rates can be generated from the relatively small numbers of older survey respondents that have the disorders (Alegria et al., 2007; Cohen et al., 2000; Depp and Jeste, 2004; Gum et al., 2009; Nelson and Rice, 1997; Palmer et al., 1999; Wu et al., 2006).

One of the few population-based sources of information about the proportion of older adults who have any of the three disorders is the Epidemiologic Catchment Area (ECA) survey that was conducted in five U.S. communities in the early 1980s. It used a structured interview based primarily on diagnostic criteria from the previous version of the DSM, DSM-III. ECA data show that the 12-month prevalence rate for bipolar disorder was 0.1 percent in older adults (Weissman et al., 1988). Another U.S. survey that provides population-based prevalence data on bipolar disorder, the NCS-R (see Box 2-2), found that 0.2 percent of older adults had the disorder (Gum et al., 2009). These rates suggest that 39,000 to 78,000 community-living older adults (rounded to 100,000 in the table) may have had bipolar disorder in 2010.

ECA data show that the 12-month prevalence rate for schizophrenia was 0.2 percent in community-living adults age 65 and older (Jeste et al., 1999). A comprehensive analysis of findings from the National Comorbidity Survey-Replication (NCS-R) (see Box 2-2), that included clinical evaluations of a subsample of NCS-R subjects, found a 12-month prevalence rate of 0.2 percent for a somewhat broader group of disorders composed of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, and other psychoses (Kessler et al., 2005). Another analysis based on Medicare claims found a 0.8 percent prevalence rate for schizophrenia in Medicare beneficiaries age 65 and older (Wu et al., 2006). The figures from these three studies suggest that in 2010, 78,000 to 300,000 older adults may have had schizophrenia.

The ECA survey is the only population-based source of U.S. data on the 12-month prevalence rate for OCD. The ECA found that 0.8 percent of community-living older adults had this condition (Wolitzky-Taylor et al., 2010), suggesting that about 300,000 older adults may have had OCD in 2010. A follow-up study showed, however, that only 19 percent of ECA subjects who met the criteria for OCD at the time of the survey still met the criteria 1 year later, and the stability of the survey-based diagnosis

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

was particularly low for older adults (Nelson and Rice, 1997). Thus, the 0.8 percent prevalence rate and the associated estimate of the number of older adults with OCD in 2010 are uncertain.

The committee believes that the prevalence rates presented above for bipolar disorder, schizophrenia, and OCD likely underestimate the true rates of these conditions in community-living older adults, but other data are not available from U.S. population-based surveys. Accurate information about the proportion and number of older adults who have these conditions is essential for evaluating the MH/SU service needs of older adults because the conditions are frequently severe, and people with the conditions often require specialty mental health services. As noted earlier, bipolar disorder and schizophrenia are core conditions in the category usually referred to as serious mental illness (SMI), a category of conditions associated with especially high mental health service needs. More accurate and up-to-date information about these conditions is needed to plan for a workforce capable of providing appropriate mental health services for older adults with SMI.

In addition to prevalence rates for the three DSM-IV-TR mental disorders, Table 2-2 shows prevalence rates for six other MH/SU conditions. The 5.2 percent rate for at-risk drinking represents the proportion of community-living adults age 65 and older with subsyndromal alcohol dependence, defined as self-reported alcohol use that meets one or two of the seven DSM-IV-TR criteria for alcohol dependence, but not the three or more criteria required for a DSM-IV-TR diagnosis of the disorder (Blazer and Wu, 2011). Using the 2010 U.S. Census figure for the population age 65 and older, the 5.2 percent rate suggests that in 2010, about 2 million community-living older adults had subsyndromal alcohol dependence.

Prevalence rates for at-risk drinking from other studies vary, depending on how the condition is defined and measured. The 2010 Behavioral Risk Factors Surveillance System (BRFSS) survey found that 3.8 percent of community-living adults age 65 and older (about 1.5 million people) reported binge drinking, defined as having four or more alcoholic drinks for women and five or more for men on at least one occasion in the previous month (Kanny et al., 2012). Compared with adults age 18-64, older adults who reported binge drinking had a significantly higher average number of drinks per occasion (5.5 drinks for those age 65 and older versus 4.1-4.7 drinks for those age 18-64). The 2010 NSDUH found that 7.6 percent of community-living older adults (about 2.9 million people) reported binge drinking (CBHSQ, 2011k,l). One-fifth of these people (about 600,000) reported heavy drinking, defined as having five or more drinks per occasion on five or more days in the previous month.

The 4.3 percent prevalence rate for anxiety symptoms represents the proportion of community-living older adults with symptoms that do not

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

meet the DSM-IV-TR criteria for a diagnosis of an anxiety disorder (about 1.7 million people in 2010). To be included in the 4.3 percent rate, individuals with anxiety symptoms also had to have substantial associated functional impairment. Other studies that did not require this high level of functional impairment have found higher rates of anxiety symptoms. One study found, for example, that 19 percent of a population-based sample of about 3,000 community-living Medicare beneficiaries ages 70-79 reported having at least one of three anxiety symptoms: feeling fearful, nervous or shaky inside, or tense and keyed up (Mehta et al., 2003). Some of these people may have had diagnosable DSM-IV-TR anxiety disorders, such as generalized anxiety disorder or major depression with anxiety, but it is not possible to determine the proportion that did.

The range of prevalence rates for depressive symptoms, 1.1 to 11.1 percent, comes from four population-based studies intended to measure depressive symptoms that did not meet the DSM-IV-TR diagnostic criteria for a depressive disorder. One study found that 11 percent of a national random sample of 137,000 community-living Medicare beneficiaries age 65 and older reported feeling “depressed or sad much of the time over the previous year” (Harris and Cooper, 2006). Two population-based studies of older adults in five North Carolina counties found that 4 and 11.1 percent, respectively, had depressive symptoms (Blazer et al., 1987; Hybels et al., 2009). A fourth study conducted in Cache County, Utah, found that only 1.1 percent of older adults had depressive symptoms (Steffens et al., 2000). This range of rates, 1.1 to 11.1 percent, suggests that 430,000 to 4.3 million older adults may have had depressive symptoms in 2010.

The researchers who conducted the Cache County study note that the relatively low rate of depressive symptoms in their study, 1.1 percent, could reflect characteristics of the sample that predict reduced risk for the condition, such as low rates of cardiovascular disease and cancer and high rates of social and religious involvement. They note alternatively that the low rate of depressive symptoms could reflect reluctance of the older adults in their sample to report “minor mental health problems” (Steffens et al., 2000).

The 0.9 percent prevalence rate for at-risk drug use in Table 2-2 comes from the 2010 NSDUH and represents the proportion of community-living adults age 65 and older who reported nonmedical use of prescription psychotherapeutic drugs in the previous year. The 0.9 percent rate indicates that about 350,000 older adults reported nonmedical use of such drugs (CBHSQ, 2011g,h). Nearly half of these people reported nonmedical use of prescription pain relievers (CBHSQ, 2011i,j).

In 2010, 1.7 percent of older adults (about 650,000 people) reported use of any illicit drugs, including 1 percent (nearly 400,000 people) who reported using marijuana (CBHSQ, 2011c,d,e,f). The proportion of older

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

adults who reported using other illicit drugs in 2010 is not given because of small numbers, but combined NSDUH data for 2005 and 2006 indicate that 0.7 percent of community-living adults age 65 and older reported using marijuana in the previous year, and less than 0.1 percent reported using cocaine, heroin, hallucinogens, or inhalants (Blazer and Wu, 2009b). Whether all older adults who use any illicit drug would be considered to have at-risk drug use is unclear, however.

Many of the figures for the nine conditions shown in Table 2-2 come from unrelated studies; thus it is not possible to determine how many older adults have more than one of the conditions. Likewise, it is not possible to determine how many older adults that have one or more of the conditions shown in Table 2-2 also have one or more of the conditions shown in Table 2-1. This information about comorbidity is required to estimate the total number of older adults who needs MH/SU services.

Prevalence of Behavioral and Psychiatric Symptoms Associated with Dementia

Table 2-3 shows prevalence rates and the estimated number of older adults that had behavioral and psychiatric symptoms associated with dementia in a one-month period. The rates come from the Aging, Demographics, and Memory Study (ADAMS), a study conducted in a stratified random sample of adults age 71 and older, drawn from the national, population-based samples used for the 2000 and 2002 Health and Retirement Study surveys (Okura et al., 2010; Plassman et al., 2007). Unlike the other data sources used to develop the figures shown in Tables 2-1 and 2-2, the ADAMS sample included nursing home residents, and the figures in Table 2-3 pertain to both community-living people and nursing home residents. The table shows the proportions of ADAMS subjects with normal cognition and dementia who had each of the symptoms, one or more symptoms, one or two symptoms, and three or more symptoms.

As shown, 57.2 percent of the older adults with dementia had one or more symptoms in the previous month, including 30.5 percent who had one or two symptoms and 26.7 percent who had three or more symptoms. The most common behavioral and psychiatric symptoms in older adults with dementia were depression or dysphoria (depressed mood) (28 percent), apathy or indifference (22.9 percent), agitation or aggression (22.5 percent), and delusions (18.2 percent) (Okura et al., 2010). Older adults with normal cognition, including older adults with MH/SU conditions but no dementia, were much less likely than those with dementia to have any of the symptoms.

ADAMS is the only U.S. study conducted to date that has measured these behavioral and psychiatric symptoms in a nationally representative sample of community-living older adults and nursing home residents, but

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-3
Proportion of Community-Living Adults and Nursing Home Residents Age 71 and Older with Normal Cognition or Dementia Who Had Associated Behavioral and Psychiatric Symptoms in the Previous Month
a

Symptomb

Older Adults with Normal Cognition n = 303 (%)

Older Adults with Dementia n = 299 (%)

Delusions

0.6

18.2

Hallucinations

0.0

14.7

Agitation/aggression

3.6

22.5

Depression/dysphoria

11.9

28.0

Anxiety

6.5

15.2

Irritability or lability

5.9

13.4

Disinhibition

0.5

11.2

Elation/euphoria

1.5

1.6

Apathy/indifference

3.0

22.9

Aberrant motor behavior

0.0

16.5

Summary figures
   One or more symptoms

17.7

57.2

   One or two symptoms

13.3

30.5

   Three or more symptoms

4.3

26.7

aThe data are weighted to adjust for the study’s complex sampling design.

bThe behavioral and psychiatric symptoms measured in the Aging, Demographics and Memory Study come from the 10-item version of the Neuropsychiatric Inventory (Cummings et al., 1994).

SOURCE: T. Okura, Bajikoen Clinic, Geriatrics Section, Tokyo, Japan, unpublished data from the Aging, Demographics, and Memory Study provided to the IOM committee, September 14, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

three other studies have measured behavioral and psychiatric symptoms associated with dementia in population-based samples at the county or local level (Chan et al., 2003; Lyketsos et al., 2000, 2002). The samples for these studies included adults age 65 and older, thus supplementing the ADAMS data on adults age 71 and older. Each of the studies found somewhat higher prevalence rates, ranging from 61 to 75 percent, for older adults with dementia and associated behavioral and psychiatric symptoms, suggesting that the 57.2 percent figure from ADAMS may be conservative.

Estimates of the total number of adults age 65 and older who have dementia range from 3.9 million to 5.1 million people (see calculations below).1 Combining these figures and the 57.2 percent rate for older adults with dementia and associated behavioral and psychiatric symptoms indicates that in 2010, 2.2 to 2.9 million older adults had such symptoms in the previous month.

Many researchers and clinicians believe that nearly all people with dementia will have behavioral and psychiatric symptoms at some time in the frequently long course of their illness (Gauthier et al., 2010; Lyketsos et al., 2011; McKeith and Cummings, 2005). Dementia-related behavioral and psychiatric symptoms often change over time as the person’s dementia worsens. Thus, the services and workforce competencies required to meet the needs of older adults with behavioral and psychiatric symptoms associated with dementia also change over time.

MH/SU Conditions for Which Population-Based Prevalence Data Are Not Available

The committee did not find population-based data to support estimates of the proportion or number of community-living older adults who have 7 of the 27 identified MH/SU conditions. The seven conditions include two DSM-IV-TR mental disorders (adjustment disorder and personality disorders) and five other MH/SU conditions (hoarding, severe

____________

1 U.S Census data show there were 25.7 million people age 71 and older in 2010, and ADAMS data indicate that 13.9 percent of people in that age group (about 3.6 million people) had dementia. U.S. Census data also show there were 14.5 million people ages 65-70 in 2010. No national data are available on the number of people ages 65-70 who have dementia, but two sources indicate that 2 percent of people in that age group, or about 290,000 people, have Alzheimerଁs disease (Brookmeyer et al., 1998; Hebert et al., 2003). Combining these figures indicates that about 3.9 million people age 65 and older had dementia in 2010. Other data from the U.S. Centers for Medicare & Medicaid Services show that in 2008, 12.6 percent of Medicare fee-for-service beneficiaries had Medicare claims with a diagnostic code for Alzheimer’s disease or another dementia (CMS, 2011). Combining the 12.6 percent rate and the U.S. Census figure for the population age 65 and older in 2010, 40.3 million people, indicates that about 5.1 million people age 65 and older had dementia in 2010.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

domestic squalor, severe self-neglect, fear of falling, and complicated grief).

Although older adults with adjustment disorder are seen with some frequency in clinical settings (Casey and Bailey, 2011; Lantz, 2008), no U.S. population-based data were found for the proportion or number of community-living adults age 65 and older who have this condition. One Swiss study found that 2.3 percent of community-living older adults had an adjustment disorder (Maercker et al., 2008).

Personality disorders were measured in the NESARC 1 and 2 surveys (see Box 2-2). The Wave 1 survey found that many community-living adults age 65 and older had one or more of seven DSM-IV-TR personality disorders; for example, 1.8 percent of older adults (about 700,000 people in 2010) had lifetime paranoid personality disorder, and 5.2 percent (about 2 million people in 2010) had lifetime obsessive-compulsive personality disorder (Grant et al., 2004). The committee did not find published data on the 12-month prevalence of the seven personality disorders. Moreover, a reanalysis of the NESARC 1 data on personality disorders in adults of all ages concluded that the published rates for lifetime prevalence were too high for each disorder because they included people who did not meet the DSM-IV-TR-required level of distress, impairment, or dysfunction associated with each of the criteria for each disorder (Trull et al., 2010). The NESARC 2 survey measured three DSM-IV-TR personality disorders that were not included in the NESARC 1 survey (Sansone and Sansone, 2011), but the committee did not find published data on 12-month prevalence of these disorders.

An analysis of findings from the Baltimore site of the Epidemiologic Catchment Area survey found that 6.6 percent of adults age 55 and older had personality disorders (Cohen et al., 1994). The disorders were diagnosed in a psychiatric evaluation using diagnostic criteria from the previous version of the DSM, DSM III. Half of those diagnosed with any personality disorder had obsessive-compulsive personality disorder. The researchers note that older adults with personality disorders are likely to express more severe symptoms of the disorder when they are experiencing stress-related situations such as serious illness, prolonged ill health, or the death of a spouse, other relative, or close friend.

The available data on three other MH/SU conditions—hoarding, severe domestic squalor, and severe self-neglect—come from case reports and administrative records of public health departments and aging and adult protective services agencies. For example:

•   Massachusetts public health officers who responded to a survey about formal complaints of hoarding received by their departments identified 471 complaints received from 1992 to 1997, suggesting

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

a 5-year rate of 0.3 complaints per 1,000 people living in the areas served by the departments (Frost et al., 2000).

•   Case records from a psychiatry agency in Sydney, Australia, showed that 173 older adults were referred to the agency for moderate or severe domestic squalor from 2000 to 2009, suggesting a 1-year rate of 0.7 referrals per 1,000 people in the agency’s service area (Snowdon and Halliday, 2011). No U.S. data were found on severe domestic squalor.

•   Ombudsman records for New Haven, Connecticut, showed that 92 of 2,161 community-living older adults followed for 9 years (4.3 percent) had confirmed self-neglect, indicating a weighted rate of 7 cases per 1,000 person-years (Abrams et al., 2002).

•   Administrative records from the Texas Adult Protective Services Division show that self-neglect by adults age 65 and older accounted for 40 percent of the 61,380 referrals for adult abuse and neglect received by the agency in 1997 (Pavlik et al., 2001).

These findings cannot be used to estimate the population-based prevalence of the three conditions because the findings only represent reported cases. Clearly, however, they have important implications for workforce competencies in public health departments and aging and adult protective services agencies.

The committee did not find population-based data on the prevalence of fear of falling, but studies conducted in convenience samples suggest that substantial proportions of older adults have this condition (Lach, 2005; Murphy et al., 2003; Oh-Park et al., 2011). A study of more than 500 community-living adults age 70 and older in New York City found, for example, that 31 percent reported fear of falling at baseline, and 45 percent of those who did not report fear of falling at baseline developed the condition in the next 2 to 5 years (Oh-Park et al., 2011).

No U.S. population-based studies of complicated grief were found. Studies conducted in Europe show that, depending on how complicated grief is defined, 0.9 to 9 percent of bereaved older adults had the condition (Forstmeier and Maercker, 2007; Kersting et al., 2011).

Prevalence of MH/SU Conditions in Older Adults
Living in Group Quarters Settings

With the exception of the figures presented earlier on behavioral and psychiatric symptoms associated with dementia, the figures presented thus far in this section have been for community-living older adults. To estimate the total proportion and number of older adults with MH/SU conditions, older adults living in group quarters settings must be added.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

As noted earlier, the 2010 Census found that 1.5 million adults age 65 and older, about 4 percent of the 40.3 million older adults in the United States, were living in group quarters settings (Census Bureau, 2010b). Of the 1.5 million older adults, 82 percent were living in nursing homes; 2 percent were living in prisons, jails, or other adult correctional facilities; and about 3 percent were homeless or living in homeless shelters or other transitional housing (Census Bureau, 2010d). The remaining 13 percent (fewer than 200,000 people) were in other group quarters settings, such as psychiatric hospitals, residential treatment centers, inpatient hospice facilities, and religious group residences. As discussed earlier, for purposes of this analysis of the proportion and number of older adults with MH/SU conditions, older adults living in assisted living, senior housing, and public housing facilities are included in the community-living population.

Prevalence of MH/SU Conditions in Older Nursing Home Residents

Table 2-4 shows the proportion and number of older adults living in nursing homes in April 2009 who had depression, anxiety disorders, bi-polar disorder, or schizophrenia and the proportion and number that had one or more of these conditions. The data come from residents’ Minimum Data Set (MDS) assessments and reflect diagnoses noted in their nursing home medical records. The diagnoses can be primary or secondary.

TABLE 2-4
Prevalence and Estimated Number of Nursing Home Residents Age 65 and Older with Selected Mental Health Conditions, 2009

Condition

Prevalence Rate (%)

Number of Residents with the Condition

Mental health conditions
   Depression

49.6

590,834

   Anxiety disorders

16.1

192,071

   Bipolar disorder

2.8

33,416

   Schizophrenia

3.6

42,521

Summary figures
   One or more conditions

56.8

675,622

SOURCE: Shaping Long-Term Care in America Project and Brown University, data provided to the IOM committee, November 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

As shown in Table 2-4, MDS data indicate that 56.8 percent of nursing residents age 65 and older (675,622 people) had at least one of the four conditions. Depression was the most prevalent condition, affecting nearly half of all older residents. Sixteen percent of residents age 65 and older had anxiety disorders, and smaller proportions had bipolar disorder and schizophrenia.

Various concerns have been raised about the precision of resident diagnoses based on MDS data. In particular, the committee believes that the 49.6 percent figure for depression in Table 2-4 probably includes both DSM-IV-TR depressive disorders and depressive symptoms that do not meet the criteria for a diagnosis of a DSM-IV-TR depressive disorder. Data on mental health conditions in nursing home residents are available from other sources, but many of these sources are quite old, and the characteristics of nursing home residents, including the proportions that have various mental health conditions, have changed in recent years (see Box 2-4).

The proportion of nursing home residents with mental health conditions will probably continue to change as nursing homes increasingly admit people for short-term, postacute care as opposed to long-term personal care and supervision. From 1999 to 2005, the proportion of long-stay residents among new admissions to nursing homes decreased from 39 to 25 percent, and the proportion of people with dementia among new admissions decreased from 24 to 18 percent (Fullerton et al., 2009). These trends reflect higher Medicare payments for postacute nursing home care as well as ongoing government and private initiatives to discourage nursing home placement from the community and encourage discharges of nursing home residents to assisted living, other residential care facilities, and home. In the same period during which admissions of long-stay residents and people with dementia decreased, however, the proportion of all residents and new residents with depression increased substantially (see Box 2-4). Thus, the likely direction of future changes in the proportion of nursing home residents with particular mental health conditions is uncertain.

In addition to the four mental health conditions shown in Table 2-4, many nursing home residents have behavioral symptoms. National data from residents’ MDS assessments show that in 2010, 28 percent of residents of all ages had such symptoms (AHCA, 2010). Many of these residents are individuals with dementia who are included in Table 2-3, and some are residents with mental health conditions who are included in Table 2-4. Thus, for purposes of this analysis of the proportion and number of older adults with MH/SU conditions, these individuals are already counted. The implications of such symptoms for residents’ service needs and related workforce requirements are discussed later in this report.

Small proportions of older nursing home residents have other MH/SU

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-4
Changing Prevalence of Mental Health Conditions in Nursing Home Residents

The proportion of nursing home residents age 65 and older with depression has increased greatly, at least since 1999. One study of residents age 65 and older in more than 5,000 nursing homes in eight states found that among those who had been in the facility for at least 90 days, the proportion with depression increased from 34 percent in 1999 to 45 percent in 2003 and 52 percent in 2007 (Gaboda et al., 2011).

Among people newly admitted to nursing homes, the proportion with depression has also increased. From 1999 to 2005, the proportion of new admissions of all ages with depression increased from 11 to 16 percent (Fullerton et al., 2009). During the same period, the proportion of new residents with bipolar disorder and schizophrenia remained the same, while the proportion of new admissions with anxiety disorders decreased from 3 to 2 percent.

New nursing home admissions with mental health conditions are more likely than other new admissions to stay in the nursing home for at least 90 days (Grabowski et al., 2009). In 2005, about half of all new admissions age 65 and older with bipolar disorder or schizophrenia who survived at least 90 days were still living in the nursing home at that time (Aschbrenner et al., 2011). The greater likelihood that new admissions with these conditions are staying in the nursing home for at least 90 days means that the overall prevalence of the conditions is probably also increasing.

conditions. The 2004 National Nursing Home Survey found, for example, that 1 percent of residents age 65 and older had alcohol dependence or abuse (Seitz et al., 2010).

Prevalence of MH/SU Conditions in Older Inmates in Adult Correctional Facilities

In 2010, 29,000 adults age 65 and older were inmates in adult correctional facilities, including federal and state prisons and local jails (Census Bureau, 2010d). Due to changes in prison sentencing and release policies enacted three decades ago, the number of older inmates is increasing rapidly. In the 4 years from 2007 to 2010, the number of older inmates

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

in federal prisons increased by 67 percent, compared with a 0.7 percent increase in the prison population as a whole (Human Rights Watch, 2012).

One study conducted in 2004 found that 36 to 52 percent of inmates age 55 and older in adult correctional facilities had mental health conditions, based on documentation of a recent diagnosis, recent mental health treatment, or symptoms that met the DSM-IV-TR diagnostic criteria for conditions, such as major depressive episode, mania, and psychosis (James and Glaze, 2006). Data from the Iowa prison system for the years 1996-2001 show that 23 percent of inmates age 55 and older had mental health conditions and 71 percent had a history of substance dependence or abuse, primarily involving alcohol (Arndt et al., 2002). The committee did not find comparable data on the proportion and number of inmates age 65 and older who have MH/SU conditions, but the proportions for inmates age 55 and older cited above suggest that 23 to 71 percent of older inmates (6,670 to 20,600 people) may have had such conditions in 2010.

Prevalence of MH/SU Conditions in Homeless Older Adults

National data on the number of homeless people come from a survey conducted on 1 day each year. In 2010, 649,917 people were found to be homeless on the designated day, including 403,308 people who were in a homeless shelter and 239,759 people who were unsheltered (HUD, 2011). The survey report does not show how many of these people were age 65 and older, but 26 percent had SMI and 35 percent had chronic substance abuse. From October 2009 to September 2010, about 44,000 adults age 62 and older spent at least one night in an emergency shelter or transitional housing (HUD, 2011), but the committee did not find information about how many of these people had MH/SU conditions.

Prevalence of MH/SU Conditions in Older Adults in Other Group Quarters Settings

Psychiatric hospitals are categorized as group quarters settings in the U.S. Census Bureau’s classification system. In 2008, 4 percent of the 180,496 people in state psychiatric hospitals were age 65 and older (about 7,200 people) (SAMHSA, 2009). The average length of stay in these hospitals was 131 days for people of all ages, but comparable information is not available for older adults.

The committee did not find information about the number of older adults in private psychiatric hospitals or their average length of stay. The committee also did not find information about the number of older adults with MH/SU conditions in other group quarters settings. It is likely that all older adults in private psychiatric hospitals and substantial

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

proportions of older adults in other group quarters settings have MH/SU conditions.

Comorbid MH/SU Conditions

As noted earlier, some older adults with MH/SU conditions have more than one such condition. Some have both a mental health condition, such as a depressive disorder, and a substance use condition, such as alcohol dependence. In addition, some older adults have more than one mental health condition, for example, a depressive disorder and generalized anxiety disorder, and some have more than one substance use condition, for example, alcohol dependence and nonmedical use of prescription drugs.

To estimate the proportion and number of older adults that have MH/SU conditions and avoid double counting, it is necessary to account for comorbidity. Some information about comorbidity is available from the large-scale, population-based surveys described in Box 2-2. This information is frequently reported for younger people but rarely reported for older adults, often because small numbers make the data for older adults unreliable. The figures on comorbidity presented below come from studies selected to illustrate the extent of comorbidity in the older population. The studies used clinical, research, or registry-based samples.

•   In a sample of 1,801 primary care patients age 60 and older who had major depression or dysthmia, 11 percent also had PTSD and 15 percent also had panic disorder (Hegel et al., 2005).

•   In a sample of 182 research subjects age 60 and older who had major depression or depressive symptoms, 23 percent also had an anxiety disorder, including 9 percent that had panic disorder and 7 percent that had social phobia (Lenze et al., 2000).

•   In a sample of 2,240 primary care patients age 65 and older, 28 percent had major depression and 12 percent of those individuals also had suicidal ideation; 21 percent of the full sample had both major depression and an anxiety disorder, and 18 percent of those individuals also had suicidal ideation (Bartels et al., 2002).

•   In a sample of 76 research subjects age 60 and older who had dysthymic disorder, 31 percent also had personality disorders, including 17 percent who had obsessive-compulsive personality disorder (Devanand et al., 2000).

•   In a research sample of 1,552 adults age 53 to 100 who had consumed any alcohol in the previous 5 years, 29 percent had depressive symptoms, and of those individuals 33 percent screened positive for alcohol abuse or misuse (Rodriguez et al., 2010).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

•   In a registry-based sample of about 15,000 veterans age 60 and older who had bipolar disorder, 9 percent also had substance abuse, 5 percent also had PTSD, and 10 percent also had other anxiety disorders (Sajatovic et al., 2006).

•   In a small research sample of 18 adults age 60 and older who had a hoarding condition, 28 percent also had major depressive disorder; 22 percent also had dysthymia; 16 percent also had OCD; 5 percent also had social phobia; and 5 percent also had general anxiety disorder (Ayers et al., 2010).

Because the samples for these studies are not population based, the findings cannot be used to determine average comorbidity figures for the older population. They do, however, portray the complex mix of comorbid MH/SU conditions that occur in some older adults and shape their service needs and related workforce requirements.

Committee Estimates of the Proportion and Number of
Older Adults with MH/SU Conditions in 2010

This section has presented information the committee was able to obtain about the proportion and number of older adults who have MH/SU conditions. Many gaps remain in the information that would be required to create a comprehensive picture of these conditions in older adults that could, in turn, be used to analyze their service needs and plan for a workforce capable of meeting those needs. The difficulties confronted by the committee in obtaining even the information presented thus far in the chapter would likely also confront others, including policy makers, administrators, and educators, who require comprehensive information to understand and address service needs. Moreover, the information presented in the chapter pertains only to national-level prevalence, whereas many policy makers, administrators, and educators need state-or local-level information, some of which would probably be even more difficult to obtain.

Table 2-5 shows the estimated number of adults age 65 and older with MH/SU conditions for which the committee found both population-based prevalence data and comorbidity information sufficient to avoid double counting. Most of the figures come from Tables 2-1, 2-3, and 2-4, shown earlier. Figures from Table 2-2 on bipolar disorder and schizophrenia are also included because the committee assumes that most community-dwelling older adults with these conditions do not have other conditions shown in Table 2-1 and therefore are not already included in the numbers shown in Table 2-5.

As shown in Table 2-5, an estimated 5.6 million to 8 million older

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-5
Estimated Number of Adults Age 65 and Older with MH/SU Conditions in 2010

MH/SU Condition

Estimated Number of Older Adults with the Conditions (Millions)

Community-living adults
   One or more of 10 conditionsa

2.6-4.0

   Bipolar disorderb

c-0.1

   Schizophreniab

0.1-0.3

Nursing home residents
   One or more of four conditionsd

0.7

Community-living adults and nursing home residents
   Behavioral and psychiatric symptoms associated with dementiae

2.2-2.9

Totals

5.6-8.0

a Estimated number of community-living people with one or more of the 10 conditions included in Table 2-1, i.e., depressive disorders, major depressive episode, dysthymic disorder, panic disorder, agoraphobia without panic, social phobia, generalized anxiety disorder, posttraumatic stress disorder, alcohol dependence or abuse, and drug dependence or abuse.

b Estimated number of community-living people with the disorder (see Table 2-2).

c The estimated number of people with the disorder is less than 50,000.

d Estimated number of nursing home residents with one or more of the four conditions included in Table 2-4.

e Estimated number of community-living people and nursing home residents with one or more of the behavioral and psychiatric symptoms associated with dementia (see Table 2-3).

adults had one or more of the MH/SU conditions included in the table. These figures represent 14 to 20 percent of the population age 65 and older in 2010.

The conditions with the highest prevalence are behavioral and psychiatric symptoms associated with dementia and depressive disorders. As shown in Table 2-5, an estimated 2.2 million to 2.9 million community-living older adults and nursing home residents have behavioral and psychiatric symptoms associated with dementia. Combining the number of community-living older adults with depressive disorders from Table 2-1 (1.2 million to 1.8 million people) and the number of older nursing home

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

residents with depression from Table 2-4 (590,000 residents) indicates that 1.8 million to 2.4 million older adults had this condition in 2010, with the caveat discussed earlier that some of the nursing home residents may have depressive symptoms rather than a DSM-IV-TR depressive disorder.

The figures in Table 2-5 represent only 13 of the 27 MH/SU conditions identified by the committee. Data presented earlier about three of the remaining conditions—depressive symptoms, anxiety symptoms, and at-risk drinking—suggest that several million older adults may have each condition. Adding older adults with these conditions to Table 2-5 would greatly increase the estimated totals. The ranges for the three conditions are wide. For example, the range for depressive symptoms is 430,000 to 4.3 million people. More importantly for estimating the proportion and number of older adults with MH/SU conditions, no information is available to account for comorbidity, and it is unclear is how many older adults who have one of the three conditions also have two or three of the conditions. Likewise, it is unclear how many older adults with one or more of the three conditions also have other conditions that are included in Table 2-5 and are, therefore, already included in the totals.

The figures for four other conditions—suicidal ideation, suicide plans and attempts, OCD, and at-risk drug use—are smaller. Nevertheless, adding older adults with each of these conditions to Table 2-5 would increase the estimated totals by about 2 million people. Again, however, no information is available to account for comorbidity.

Adding older adults with the remaining seven conditions for which sufficient population-based prevalence data were not found—adjustment disorders, personality disorders, hoarding, severe domestic squalor, severe self-neglect, fear of falling, and complicated grief—would probably increase the estimated totals. On the other hand, some, and perhaps many, older adults who have these conditions may also have one or more of the other conditions included in Table 2-5 and therefore, may already be included in the totals.

Gaps in the information needed to analyze MH/SU service needs and related workforce requirements exist across different categories of conditions and settings. In general, more prevalence and comorbidity information is available for DSM-IV-TR mental disorders than for other MH/SU conditions. Still, the available information about two DSM-IV-TR disorders, adjustment disorder and personality disorders, is not sufficient to allow for inclusion of these conditions in the committee’s estimated totals. The available prevalence data for some DSM-IV-TR disorders are quite old, and as noted earlier, the committee believes the data for bipolar disorder in community-living older adults probably underestimate its true prevalence.

With the exception of nursing home residents, more prevalence and

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

comorbidity information is available for older adults living in the community than in group quarters settings. The number of older adults in non–nursing home group quarters settings, such as adult correctional facilities and homeless shelters, is small in comparison with the numbers in the community and nursing homes. As a result, even if large proportions of older adults in these settings have MH/SU conditions, the numbers would probably be too small to change the committee’s estimated totals. For purposes of analyzing service needs and workforce requirements, however, it is important to know how many older adults in non–nursing home group quarters settings have MH/SU conditions. The same is true for hoarding, severe domestic squalor, and severe self-neglect, where the number of people with the conditions is relatively small, but the implications of the conditions for workforce requirements in public health departments and aging and adult protective services agencies are significant.

Committee Estimates of the Proportion and
Number of Older Adults with SMI in 2010

The estimated proportion and number of people with SMI depend on how SMI is defined. In general, the term is intended to identify very serious mental health conditions that create a high need for mental health services. Over the years, other terms have been used, such as severe mental illness and severe and persistent mental illness. Regardless of the specific term, however, people with the identified conditions generally have been accorded high priority for publicly funded mental health services (Goldman and Grob, 2006).

As noted earlier, schizophrenia and bipolar disorder are included in all definitions of SMI. Severe forms of other mental disorders, such as major depression, are sometimes also included, but substance use conditions are not included.

In 1993, people with serious mental illness were defined in federal regulations as people “age 18 and older, who currently or at any time in the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that has resulted in functional impairment that substantially interferes with or limits one or more major life activities” (SAMHSA, 1993). The regulations also stated that, “In the case of adults, this most seriously mentally ill population is largely composed of persons with schizophrenia and major mood disorders.” Substance use conditions were explicitly excluded. Fiscal year 1993 federal appropriations legislation used a different term, severe mental illness, and specified “disorders with psychotic symptoms such as schizophrenia, schizoaffective disorder,

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

manic depressive disorder, autism, as well as severe forms of other disorders such as major depression, panic disorder, and obsessive compulsive disorder” (Narrow et al., 2000).

In 2006, SAMHSA convened an expert panel to recommend ways to estimate the prevalence of SMI in people of all ages. Based on the panel’s recommendations, SAMHSA developed a detailed methodology for use with data from the National Survey on Drug Use and Health (NSDUH), including follow-up telephone interviews conducted by a mental health clinician with a subsample of NSDUH respondents (CBHSQ, 2012b). Using that methodology, data from the 2010 NSDUH show that 1.4 percent of community-dwelling adults age 65 and older, about 535,000 people, had SMI (CBHSQ, 2012d).

The 535,000 figure does not include nursing home residents or older adults living in certain other group quarters settings, and the SAMHSA methodology has not been applied to these people. As shown earlier, about 76,000 nursing home residents had bipolar disorder and schizophrenia in 2009 (see Table 2-4). It is not clear whether all these individuals would be found to have SMI based on the SAMHSA methodology or how many additional nursing home residents and other older adults who are homeless or living in adult correctional facilities, psychiatric hospitals, or other residential treatment facilities would be found to have SMI based on the methodology. At a minimum, combining the 535,000 community-living older adults identified as having SMI based on the SAMHSA methodology and the 76,000 nursing home residents with bipolar disorder and schizophrenia indicates that at least 611,000 older adults (about 1.5 percent of the older population) had SMI in 2010.

Definitions of SMI have not been developed specifically for older adults. In fact, with some notable exceptions (see, e.g., Bartels, 2004, 2011), SMI research and analyses to date have focused almost entirely on people under age 65.

In considering how to define SMI for this report, the IOM committee wanted to identify older adults with very serious mental health conditions that create not only high need for mental health services, but also high priority for workforce training and competencies. While acknowledging the extensive conceptual work and research conducted to develop the SAMHSA methodology, the committee was uncertain about whether this methodology adequately identifies older adults with SMI. The committee considered whether SMI in older adults should ideally be defined more in terms of functional impairment and less in terms of particular mental health conditions, but a methodology for estimating the proportion and number of older adults with SMI defined in this way has not been developed.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

To estimate the prevalence of SMI in older adults using information obtained for this report, the committee decided to focus on four mental health conditions: schizophrenia, schizoaffective disorder, bipolar disorder, and treatment-refractory major depression. No population-based data are available on the prevalence of treatment-refractory major depression, so data on major depressive episode are used as a substitute in developing the estimate. The committee’s estimate is based on the following figures presented earlier in this chapter:

•   the range of figures for major depressive episode in community-living older adults: 1.2 million to 1.7 million people (see Table 2-1);

•   the figure for nonaffective psychoses, including schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, and other psychosis in community-living older adults: 78,000 people (Kessler et al., 2005);

•   the range of figures for bipolar disorder in community-living older adults: 39,000 to 78,000 people (see Table 2-2); and

•   the number of nursing home residents with schizophrenia and bipolar disorder: 76,000 (see Table 2-4).

Combining the figures above indicates that 1.4 million to 1.9 million older adults, 3 to 4.8 percent of the older population, had SMI in 2010. Using a range of these figures and the SAMHSA figures noted earlier, the committee estimates that in 2010, 611,000 to 1.9 million older adults (1.5 to 4.8 percent of the older population) had SMI.

A study of MH/SU conditions in older adults in Massachusetts (Clark et al., 2009) provides state-level information about the prevalence of SMI, defined in the study as schizophrenia and paranoid disorders, bipolar disorder, and major depression (see Table 2-6). The study sample includes all older Medicare and Medicaid beneficiaries in the state as of January 1, 2005, with the exception of Medicare managed care enrollees. People with MH/SU conditions were identified by the presence of a code for the condition as either a primary or secondary diagnosis on at least one Medicare or Medicaid claim during the year. Medicare managed care enrollees were excluded because Medicare claims are not submitted for them. People were counted as living in long-term care (LTC) if they were in a nursing home or hospital for a combined total of 120 days or longer during 2005.

As shown in Table 2-6, 5.4 percent of older Medicare and Medicaid beneficiaries had SMI in 2005, including 1.1 percent who had schizophrenia and paranoid disorders, 1.1 percent who had bipolar disorder, and 3.2 percent who had major depression. Among those with SMI, the data indicate that

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-6 Number and Proportion of Massachusetts Medicare and Medicaid Beneficiaries Age 65 and Older with Serious Mental Illness, Other Mental Illness, and No Mental Illness by Age, Gender, Place of Residence, Insurance, and Coexisting Dementia, 2005, N = 679,182a

Characteristics Mental Health Status
Serious Mental Illness (SMI) Serious Mental Illness (SMI) Conditions Other Mental Illness No Mental Illness
Schizophrenia and Paranoid Disorders Bipolar Disorder Major Depression
Number 36,686 7,174 7,780 21,732 90,462 552,034
5.4% 1.1% 1.1% 3.2% 13% 81%
Age
65-74 15,161 2.971 3,406 8.784 32.484 275,003
41% 41% 44% 40% 36% 50%
75-84 14,126 2.649 3,039 8.438 36.232 200.792
39% 37% 39% 39% 40% 36%
85+ 7.399 1,554 1,335 4,510 21.746 76.239
20% 22% 17% 21% 24% 14%
Gender
Male 11.074 2.166 2,514 6.394 27,754 235,812
30% 30% 32% 29% 31% 43%
Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×
Female 25,612 5,008 5,266 15,338 62,708 316,222
70% 70% 68% 71% 69% 57%
Residence
Community 32,492 5,798 6,962 19,372 85,913 550,068
89% 81% 89% 91% 95% 99.6%
Long-term care 4,194 1,376 818 2,000 4,549 1,966
11% 19% 11% 9% 5% 0.4%
Insurance
Medicare only 20,532 2,373 4,721 13,946 64,683 467,011
56% 33% 61% 64% 72% 85%
Medicaid only 508 b b b 738 18,008
1% b b b 0.8% 3%
Dual eligible 15,646 4,801 3,059 7,786 25,041 67,015
43% 67% 39% 36% 28% 12%
Dementia 16,632 4,421 3,611 8,600 30,362 37,309
45% 62% 46% 40% 34% 7%

a Some data taken from R. E. Clark, University of Massachusetts Medical School, unpublished data provided to the IOM committee, November 2011.

b Numbers were not reported because of small cell size (<11) in some disease groups for Medicaid-only sample members.

SOURCES: Clark et al., 2009; Lin et al., 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

•  89 percent lived in the community, including 81 percent of those with schizophrenia and paranoid disorders, 89 percent of those with bipolar disorder; and 91 percent of those with major depression;

•  70 percent were women, including 70 percent of those with schizophrenia and paranoid disorders, 68 percent of those with bipolar disorder, and 71 percent of those with major depression;

•  43 percent were dually eligible for Medicare and Medicaid, including 67 percent of those with schizophrenia and paranoid disorders; 39 percent of those with bipolar disorder; and 36 percent of those with major depression; and

•  45 percent had coexisting dementia, including 62 percent of those with schizophrenia and paranoid disorders; 46 percent of those with bipolar disorder; and 36 percent of those with major depression.

There are several caveats with respect to the data from the Massachusetts study. The data represent only one state, and comparable data from other states would undoubtedly differ. In addition, the accuracy of diagnoses based on Medicare and Medicaid claims is uncertain, and the exclusion of Medicare managed care enrollees means that 18 percent of older Medicare beneficiaries in the state are not represented (Lin et al., 2011). Acknowledging these caveats, the data provide state-level information about the proportion, number, and characteristics of this high-priority population that is useful for analyzing their service needs and related workforce requirements. Especially notable are the high proportions of older adults with SMI that were dual eligibles, had coexisting dementia, and were living in the community as opposed to long-term care settings.

PREVALENCE OF MH/SU CONDITIONS IN SIX
SUBGROUPS OF THE OLDER POPULATION

The prevalence rates and estimated numbers of older adults with MH/SU conditions discussed in the previous section pertain to the older population as a whole. This section focuses on differences in prevalence rates for six subgroups within that population:

1.   Adults ages 65-74, 75-84, and 85 and older

2.   Older women and men

3.   Racial and ethnic groups

4.   Residents of assisted living, senior housing, and public housing facilities

5.   Older adults who are dually eligible for Medicare and Medicaid

6.   Older veterans

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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As discussed in the section, differences in prevalence rates and estimated numbers of people with MH/SU conditions in the older population as a whole versus in these subgroups have important implications for service needs and workforce requirements.

Adults Ages 65-74, 75-84, and 85 and Older

Among the 40.3 million adults age 65 and older in 2010, more than half (54 percent) were age 65-74, about 21.7 million people (Census Bureau, 2011b). The 13.1 million adults age 75-84 constituted 32 percent of the older population, and the 5.5 million adults age 85 and older, often referred to as the oldest-old, constituted the remaining 14 percent.

National data on prevalence rates and numbers of older adults with MH/SU conditions in the age subgroups 65-74, 75-84, and 85 and older are not easily accessible. Published reports of findings from population-based surveys of MH/SU conditions rarely include information about age subgroups within the older population. Published reports from some of the surveys provide information about “older people” defined as adults age 50 and older or 55 and older, rather than adults age 65 and older. The limited amount of information about age subgroups within the older population in published reports from these surveys is often attributed to small sample sizes, suggesting the need for larger samples. At the same time, since the data exist, at least for the age groups 65 and older, 65-74, and 75 and older, the limited amount of published information probably also reflects decisions about the relative importance of including information about people in older versus younger age groups in published reports of survey findings.

Some survey-based information about the prevalence of MH/SU conditions for adults ages 65 and older, 65-74, and 75 and older can be accessed online, and additional information can be obtained through special analyses conducted by the agency that funded the survey or other researchers who have access to the raw data. Prevalence rates for adults age 65-74 and 75 and older for the MH/SU conditions that were measured in the population-based surveys of MH/SU conditions described in Box 2-2 were provided to the IOM committee by the Center for Multicultural Mental Health Research and SAMHSA. Sample sizes were too small to generate reliable rates for adults age 85 and older.

For the 10 MH/SU conditions measured in each of three surveys (the CPES, NESARC 1, and NESARC 2), prevalence rates were generally higher for the age group 65-74 than the age group 75 and older, although some differences are very small (Center for Multicultural Mental Health Research, 2011). The midpoint of the rates for having one or more of the 10 conditions is 9.5 percent for adults age 65-74 and 6.9 percent for adults age

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

75 and older. The differences in rates for particular MH/SU conditions are generally smaller, but show the same pattern of higher rates in younger versus older age groups within the older population.

Prevalence rates for substance use conditions measured in the NSDUH and calculated for the age groups 65-69, 70-74, and 75 and older also show this pattern. The 2010 rate for alcohol dependence or abuse in the past year was 2.8 percent for adults age 65-69, 1.8 percent for those age 70-74, and 1.4 percent for those age 75 and older.2 Likewise, the 2010 rate for binge drinking in the past month was 11 percent for adults age 65-69, 8.6 percent for those age 70-74, and 4 percent for those age 75 and older. The 2009 National Health Interview Survey (NHIS) also found higher rates of binge drinking for adults age 65-74 than for those age 75 and older (NCHS, 2011b).

For drug dependence or abuse in the past year, prevalence rates from the 2010 NSDUH are higher for adults age 65-69 (0.2 percent), decreasing to rates too low to be reported for adults age 70-74 and 75 and older.2 The 2010 rate for nonmedical use of prescription drugs was 1.3 percent for adults age 65-69, compared to 0.7 percent for adults age 70-74 and 75 and older. Similarly, the 2010 rate for nonmedical use of prescription pain relievers was 0.5 percent for adults age 65-69 compared to 0.4 percent for adults age 70-74 and 75 and older. The few exceptions to the pattern of higher rates in the age group 65-74 than in the age group 75 and older all come from one of the surveys, the CPES (see Box 2-2). CPES data show slightly lower proportions of adults age 65-74 than adults age 75 and older for three conditions: panic disorder, suicidal ideation, and depressive symptoms.

Very little information is available about prevalence rates for MH/SU conditions in the oldest old, with one important exception. For at least the past 60 years, reported suicide rates have been higher for white men age 85 and older than for any other group. Suicide rates for white men age 75-84 have been second highest in the same period (NCHS, 2011a). Rates are lower for older men in other racial and ethnic groups and for women in all age groups.

Prevalence rates for behavioral and psychiatric symptoms associated with dementia are probably higher for the oldest old than for adults ages 65-74 and 75-84. This is because dementia is much more common in adults age 85 and older than in the younger age subgroups (Brookmeyer et al., 1998; Hebert et al., 2003). It is not clear whether adults age 85 and older with dementia are more likely than adults ages 65-74 or 75-84 with dementia to have behavioral and psychiatric symptoms.

____________

2 Center for Behavioral Health Statistics and Quality, unpublished data from the 2010 National Survey on Drug Use and Health provided to the IOM committee, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Psychotic symptoms, including hallucinations, delusions, and paranoid ideation, have been found to occur in 7 to 10 percent of adults age 85 and older in population-based Swedish samples (Ostling and Skoog, 2002; Ostling et al., 2007). Similar data are not available from population-based samples in the United States.

Calculations by the committee based on data from the Massachusetts study discussed earlier (Clark et al., 2009) indicate that 7 percent of Medicare and Medicaid beneficiaries age 85 and older had SMI. Another 20.6 percent of those age 85 and older had other mental health conditions, including other depression, anxiety, and other mental illness. Interestingly, the rate for SMI in the oldest old is higher than in those ages 65-74 and 75-84 in the Massachusetts sample (7 percent for those age 85 and older versus 4.7 percent for those age 65-74 and 5.6 percent for those age 75-84). Likewise, the rate for schizophrenia is higher in the oldest old than in the younger age subgroups (1.5 percent of those age 85 and older versus 0.9 percent of those age 65-74 and 1.1 percent of those age 75-84). This pattern of higher rates for the oldest old in comparison with those age 65-74 and 75-84 holds true for each mental health condition measured in the Massachusetts study. It is not clear whether the pattern would also be seen in national, population-based samples if the samples were large enough to support accurate findings for the oldest old.

As discussed later in this chapter, the number of adults age 85 and older is expected to increase from 5.5 million in 2010 to 8.7 million in 2030 (Census Bureau, 2011b). Information about the prevalence of MH/SU conditions in the oldest old is needed to plan for adequate services and workforce competencies to care for this population that also has very high rates of coexisting physical health conditions and cognitive and functional impairments.

Older Women and Men

On average, women live longer than men and, therefore, constitute a larger proportion of the older population. Among the 40.3 million adults age 65 and older in 2010, 22.9 million (57 percent) were women and 17.4 million (43 percent) were men (Census Bureau, 2011a). The difference is greater in older age subgroups. Among the 5.5 million adults age 85 and older in 2010, 3.7 million (67 percent) were women, and 1.8 million (33 percent) were men.

Because of the larger number of women in the older population, one would expect to find larger numbers of older women than older men with mental health conditions, even if the proportion of older women and men with each condition were the same. For most conditions, however, the proportion of older women with the conditions is higher. This is true

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

for 8 of the 10 conditions measured in three population-based surveys of MH/SU conditions described in Box 2-2 (CPES, NESARC 1, and NESARC 2). For example, the midpoint of the prevalence rates from the three surveys for depressive disorders is 4.8 percent for older women and 2.6 percent for older men (Center for Multicultural Mental Health Research, 2011). Likewise, the midpoint of the rates for having one or more of the 10 conditions is 9.8 percent for older women and 6.4 percent for older men.

The two conditions for which these surveys found lower rates for older women than older men are alcohol dependence or abuse, where the midpoint of rates is 0.3 percent for older women and 1.9 percent for older men, and drug dependence or abuse, where the midpoint of the rates is 0.05 percent for older women and 0.11 percent for older men (Center for Multicultural Mental Health Research, 2011). The 2010 National Survey of Drug Use and Health also found lower rates for alcohol dependence or abuse, drug dependence or abuse, or both conditions for older women than men (1.3 percent for older women versus 3.1 percent for older men).3 Similar patterns have been found in studies of some other MH/SU conditions. Older women are more likely than older men to have depressive and anxiety symptoms that do not meet the criteria for a DSM-IV-TR diagnosis of a depressive or anxiety disorder (Grenier et al., 2011; Judd et al., 1996; Lyness et al., 2009). In contrast, older women are less likely than older men to have at-risk drinking. The 2005 and 2006 NSDUH surveys show, for example, that 3 percent of women age 65 and older reported binge drinking, compared with 15 percent of men in that age group (Blazer and Wu, 2009a).

Only about half of all older adults drink alcohol. In 2010, 47 percent of women age 65 and older and 55 percent of men in that age group reported having any alcoholic drinks in the previous year.3 Women are more susceptible than men to the physical effects of alcohol throughout their lives, but age-related physiological changes can increase the susceptibility of all older adults to alcohol-related problems (Blow and Barry, 2002; Epstein et al., 2007).

In 2010, 1.4 percent of older women and 2.2 percent of older men reported past-year use of illicit drugs, including marijuana, cocaine, heroin, and prescription psychotherapeutic medications, such as pain relievers and antianxiety medications that are used for nonmedical purposes.3 Many older adults take prescription psychotherapeutic medications. From 2005 to 2008, 18 percent of older women and men reported taking prescription pain relievers in the past month, and 12 percent of older women and 7 percent of older men reported taking prescription sedatives,

____________

3 Center for Behavioral Health Statistics and Quality, unpublished data from the 2010 National Survey on Drug Use and Health provided to the IOM committee, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

hypnotics, and antianxiety medications (NCHS, 2011c). These medications are needed and effective for many older adults, but they have high potential for negative side effects, including addiction, overdoses, and impaired physical and cognitive functioning, the likelihood of which is increased by age-related physiological changes (Blow, 1998; Simoni-Wastila, 2000; Simoni-Wastila and Yang, 2006).

Wide exposure to prescription pain relievers, antianxiety medications, and other prescription psychotherapeutic medications creates high risk for misuse, which can range from infrequent, intentional or unintentional use of a higher dose than prescribed to repeated use of high doses, sometimes combined with alcohol and over-the-counter sleeping medications that exacerbate their effects (Blow and Barry, 2002; Epstein et al., 2007; Gleason et al., 1998; Simoni-Wastila and Yang, 2006). Older women are particularly at risk for misuse of antianxiety medications, usually benzodiazepines. Long-term use of these medications is not recommended, especially for older adults (Blow, 1998). Yet longitudinal studies have found that older women were not only more likely than older men to be taking the medications at the beginning of the study, but also more likely to be taking them 1 to 10 years later (Blazer et al., 2000b; Gray et al., 2003). Greater awareness of the risks associated with misuse of these prescription medications is important for older adults, especially older women, and for the physicians and other health care professionals who prescribe the medications. Other health care, residential care, and home-and community-based service providers should also be aware that many older adults use these medications and observant for possible misuse and its negative side effects.

Racial and Ethnic Groups

In 2010, 80 percent of the population age 65 and older was non-Hispanic white; 8 percent was African American; 7 percent was Hispanic/ Latino; 3 percent was Asian; and 1 percent was American Indian, Native Alaskan, Native Hawaiian, or Pacific Islander. The remainder was two or more races or ethnicities (Census Bureau, 2011c).

Prevalence rates for MH/SU conditions differ for older adults in various racial and ethnic groups. Table 2-7 shows these differences for community-living adults age 65 and older in four groups, with the Asian and American Indian, Native Alaskan, Native Hawaiian, and Pacific Islander groups combined because of small numbers. The data come from three of the national, population-based surveys of MH/SU conditions described in Box 2-2 (CPES, NESARC 1, and NESARC 2). All the conditions are DSM-IV-TR mental disorders. The figures show the midpoint of

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-7
12-Month Prevalence of Selected Mental Disorders in Community-Living Adults Age 65 and Older in the United States in Four Racial and Ethnic Groups

Racial or Ethnic Group
Mental Disorder White
(%)
African
American
(%)
Hispanic/
Latino
(%)
Asian/
Native
Hawaiian/
Pacific
Islander
(%)
Menial health disorders
   Depressive disorders 3.8 3.6 6.9 4.0
   Major depressive episode 3.5 3.4 6.1 33
   Dysthymic disorder 1.0 0.7 2.0 0.7
   Panic disorder 0.9 0.7 1.8 1.8
   Agoraphobia without panic 0.1 0.2 0.3 0.1
   Social phobia 1.7 1.7 1.1 15
   Generalized anxiety disorder 1.5 1.7 1.7 25
   Posttraumatic stress disorder (PTSD)a 1.5 2.3 3.2 13
Substance use disorders
   Alcohol dependence or abuse 1.1 1.1 1.2 0.0
   Other drug dependence or abuse 0.1 0.1 0.1 0.0
Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×
Summary figures
   One or more of the disorders 8.0 8.7 11.7 9.0
   Two or more of the disorders 2.2 2.1 3.1 1.6
   Three or more of the disorders 0.6 0.7 1.2 0.6

a The NESARC 1 survey did not measure PTSD; thus, the PTSD figures represent the midpoint of the prevalence rates from only two surveys, the CPES and NESARC 2.

SOURCE: Center for Multicultural Mental Health Research, 2011.

the range of prevalence rates from the three surveys for each disorder and for one or more, two or more, and three or more disorders.

The figures in Table 2-7 suggest that prevalence rates for some disorders and for one or more, two or more, and three or more disorders may be higher for Hispanic/Latinos than for the other three groups. Differences in the midpoints of rates among the groups have not been tested for statistical significance, however.

Until about 10 years ago, little information was available from national, population-based surveys about the prevalence of MH/SU conditions in racial and ethnic groups in the older population. Starting in 2001, several national surveys included large enough numbers of people in various groups to allow for meaningful prevalence estimates. In addition, NESARC conducted interviews in English and Spanish, and the National Latino and Asian American Study conducted interviews in English, Spanish, Tagalog, Vietnamese, and Mandarin, thus allowing people with limited English proficiency to be interviewed in their primary language (Alegria et al., 2007).

Findings from these national, population-based surveys provide valuable

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

information about differences among racial and ethnic groups in prevalence rates for MH/SU conditions. Yet, aggregation of findings for the four major groups shown in Table 2-7 obscures important differences in rates within each of the groups. Some of these differences pertain to subgroups defined specifically by race or ethnicity, for example, Puerto Rican and Mexican American subgroups within the Hispanic/ Latino group. Other differences pertain to an array of factors that have been found to be related to the prevalence of MH/SU conditions in older adults in various racial and ethnic groups. These factors include whether the person was born in the United States or elsewhere, and, if born elsewhere, how old the person was at the time of immigration; how long the person has been in the United States; the person’s gender, education, and income; perceived financial strain; life events; and region of the country. The following examples come from studies selected to illustrate the interrelationships among these factors and prevalence rates:

•   Among older Asian Americans living in the United States, the prevalence of major depression was much higher for Chinese Americans age 65-74 than for Filipino and Vietnamese Americans in that age group. In contrast, prevalence was lower for Chinese Americans age 75 and older than for adults in that age group in the other two Asian subgroups. Likewise, within the Hispanic/ Latino group, prevalence of major depression was higher for Cuban Americans and Puerto Ricans age 65-74 than for Mexican Americans in that age group, and much higher for Puerto Ricans age 75 and older than for adults age 75 and older in the other two Hispanic/Latino subgroups (Gonzalez et al., 2010).

•   Among older blacks living in the United States, the prevalence of major depressive disorder was much higher for older blacks of Caribbean descent than for African Americans (11 percent versus 3 percent, respectively) (Aranda et al., 2011).

•   Among older Asian Americans living in the United States, prevalence of MH/SU conditions was higher for those born in the United States than for those born outside the country. For Asian Americans born outside the United States, prevalence was higher for those who arrived in the country as children than for those who arrived as adolescents or adults (Breslau and Chang, 2006).

•   Among older Mexican Americans living in the United States, prevalence of depressive symptoms was higher for those born outside the United States than for those born in the United States, and highest for those who arrived in this country less than 6 years before the survey (Black et al., 1998). Within these three categories (born in the United States, arrived in the United States less

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

than 6 years before the survey, and arrived in the United States 6 or more years before the survey), prevalence differed for women and men. Among older Mexican Americans who were born in the United States, prevalence of depressive symptoms was 28 percent for women and 17 percent for men. Among those who arrived in the United States 6 or more years before the survey, prevalence was also higher for women than men (35 percent versus 15 percent, respectively). Among those who arrived more recently (less than 6 years before the survey), prevalence was very high for both women and men (57 percent for older Mexican American women and 58 percent for older Mexican American men). Low levels of education, low income, financial stress, recent death of a spouse, and health problems were also associated with higher prevalence of depressive symptoms (Chiriboga et al., 2002).

•   Among African Americans age 55 and older, prevalence of any of 13 MH/SU conditions was lower for those living in the south than for those living in other parts of the country (Ford et al., 2007). Prevalence of major depressive disorder was 2.6 percent for those living in the south, compared with 6 percent for those living outside the south (Aranda et al., 2011). The researchers hypothesize that these findings may be due to protective effects of greater religious involvement and the larger family networks of older blacks living in the south.

For policy makers, administrators, and others who have to plan services to meet the needs of older adults with MH/SU conditions, the complex interrelationships among race, ethnicity, and the associated factors illustrated above mean that aggregated information about the prevalence of these conditions in the four or five major racial and ethnic groups is not sufficient. Information about differences within these groups is also required. For the workforce, the need for diversity training and competency as well as access to staff with proficiency in numerous languages is also clear. These implications are relevant now and will affect the availability of appropriate MH/SU services for increasing numbers of older adults as racial and ethnic group populations grow in coming years.

Residents of Assisted Living, Senior Housing, and Public Housing Facilities

Many older adults live in assisted living, senior housing, and public housing facilities. The first National Survey of Residential Care Facilities found that in 2010, there were about 31,100 assisted living and other residential care facilities in the United States (Park-Lee et al., 2011). On any

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

given day in 2010, an average of 730,000 people were living in these facilities, 89 percent of whom (about 650,000 people) were age 65 and older (Caffrey et al., 2012). The facilities included in the survey were licensed or otherwise regulated at the state level and had to provide room and board, at least two meals per day, around-the-clock supervision, and assistance with personal care, such as bathing and dressing, or health-related services, such as medication management. Among the 31,100 facilities, 65 percent had 4 to 25 beds and provided care for about one-fifth of all residents. The remaining 35 percent were larger, with 26 to more than 100 beds, and provided care for four-fifths of all residents.

About 300,000 adults age 65 and older were living in federal government–supported public housing facilities in the period from November 2010 to February 2012 (HUD, 2012), and some of those facilities are designated specifically as senior housing. Older adults also live in public housing facilities run by local housing authorities with federal, state, and local government funding, and some of these facilities are designated specifically as senior housing. Public housing and senior housing facilities vary greatly in the extent to which they provide services that could help older adults with MH/SU conditions, but various public and private organizations have ongoing projects to increase services for older adults in such facilities.

Assisted living, senior housing, and public housing facilities are sometimes referred to as congregate-living facilities because their residents live in close proximity. In the context of this report, it is important to note that practical and effective approaches for the detection, diagnosis, treatment, and ongoing management of MH/SU conditions in older adults probably differ in congregate-living facilities versus single-family housing.

Recently published national data show that in 2010, 28 percent of all residents in assisted living and residential care facilities had been told by a physician that they had depression, and 42 percent had been told they had dementia (Caffrey et al., 2012). No other national data are available about the proportion or number of residents of assisted living, senior housing, and public housing facilities who have MH/SU conditions, but findings from three studies suggest that many do. One study of 198 residents age 58-104 in 22 randomly selected assisted living facilities in central Maryland used an expert panel to identify those with mental disorders based on resident records and in-person interviews (Rosenblatt et al., 2004). The study found that 26 percent of the residents had one or more mental disorders, including 19 percent with mood disorders, 13 percent with anxiety disorders, and 12 percent with psychotic disorders. In addition, 68 percent of the residents had dementia, and 14 percent had both dementia and a mental disorder. Among those with dementia, 83 percent had exhibited behavioral and psychiatric symptoms in the previous month.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

A second study of 2,078 residents age 65 and older in 193 assisted living and other residential care facilities in four states used various sources of information to identify residents with mental health conditions (Gruber-Baldini et al., 2004):

•  28 percent were found to have any mental or psychiatric illness, based on resident records or the report of an informant, usually a family member.

• 14 percent were found to have depression based on their score on a widely used depression assessment instrument.

•  13 percent were found to have psychosis based on staff report of the presence of hallucinations or delusions in the previous 7 days.

•  About half of the 2,078 residents had dementia, and 49 percent of them were found to have one or more of four kinds of behavioral symptoms in the previous week: (1) physically aggressive symptoms, such as hitting, kicking, biting, throwing things, or self-abuse; (2) physically nonaggressive symptoms, such as pacing, restlessness, and inappropriate dressing or undressing; (3) verbal symptoms, such as screaming, constant requests for help, and repeated calling out; and (4) resistance to care, including resistance to taking medications and resistance to help with bathing, dressing, and other activities of daily living. As shown in Table 2-8, large proportions of residents with any mental or psychiatric illness, depression, or psychosis also had one or more of these behavioral symptoms in the previous week.

These data on residents with depression and psychosis who also had behavioral symptoms are surprising because the proportions are higher than the comparable proportions for residents with dementia. The proportions of residents with any mental or psychiatric illness who also had behavioral symptoms are only slightly below the comparable proportions for residents with dementia.

A third study of 945 residents age 60 and older in six public housing facilities designated specifically for seniors used in-person screening tests and structured interviews to identify residents with mental disorders (Rabins et al., 1996):

•  8 percent were found to have mood disorders, including 5.6 percent with major depression, 1.7 percent with dysthymia, and 0.4 percent with bipolar disorder;

•  4.6 percent were found to have psychotic disorders, including 2.1 percent with schizophrenia;

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-8
Proportion of Assisted Living and Residential Care Residents with Behavioral Symptoms in the Previous Week, by Mental Health Conditions and Dementia

Condition Behavioral Symptoms
One or
More
Behavioral
Symptoms
(%)
Physically
Aggressive
Symptoms
(%)
Physically
Nonaggressive
Symptoms
(%)
Verbal
Symptoms
(%)
Resistance
to Care
(%)
Any mental or psychiatric illness 40 17 28 29 15
Depression 77 38 50 61 32
Psychosis 69 30 50 52 31
Dementia 49 19 34 31 17

SOURCE: Gruber-Baldini et al., 2004.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

•   2 percent were found to have anxiety disorders, including 0.4 percent with panic disorder and 0.8 percent with generalized anxiety disorder; and

•   4.4 percent were found to have substance use disorders, including 4 percent with alcohol dependence or abuse and 0.5 percent with drug dependence or abuse.

The findings from these three studies are not precisely comparable because they focused on different MH/SU conditions and used different methods to identify residents with the conditions. Likewise, findings from the three studies are not precisely comparable with findings discussed earlier in this chapter on MH/SU conditions in community-living older adults and nursing home residents. On the other hand, some differences in the prevalence of MH/SU conditions among older adults in these settings are obvious. With respect to major depression, which was measured in public housing, assisted living and nursing home residents and community-living people, the proportion of older adults with the condition is lowest in those living in the community; it is progressively higher in public housing residents and assisted living residents, and highest in nursing home residents. For alcohol dependence or abuse, which was measured in public housing– and community-living older adults, the proportion of public housing residents with the condition was higher. Similarly, for psychosis, which was measured in public housing and assisted living residents, the proportion of assisted living residents with the condition was higher.

Two other studies that included both assisted living and nursing home residents found little, if any, difference in the proportion of residents who had behavioral and psychiatric symptoms associated with dementia. One study of 347 adults age 65 and older with dementia in 10 nursing homes and 45 assisted living facilities found that 66 percent of the nursing home residents and 56 percent of the assisted living residents had behavioral symptoms (Boustani et al., 2005). Another study of 1,252 adults age 65 and older with dementia in 40 nursing homes and 166 assisted living facilities found no difference in the proportions that also had behavioral symptoms (Sloane et al., 2005).

Many factors other than an older person’s MH/SU conditions affect whether the person will be living in the community, a public housing, senior housing, assisted living facility, or a nursing home. In addition to the person’s and family’s preferences and whether the person has coexisting physical health conditions, cognitive and functional impairments, and a caregiver at home, these factors include federal, state, and local government policies that affect the number of available beds in various types of congregate-living facilities. Such policies determine, for

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

example, which types of facilities can admit older adults with MH/SU conditions and whether Medicaid or other public funding is available to people with these conditions in the facilities that can admit them. Some states do not allow assisted living facilities to admit people with mental health conditions, and some require a special license or limit the number of people with these conditions that can be admitted (Becker et al., 2002; Polzer, 2011). All states provide Medicaid funding for nursing home care for people who meet the state’s financial and functional eligibility criteria, but some states also provide subsidies for low-income assisted living residents (Polzer, 2011). States vary greatly in the amount and types of home-and community-based services they provide (Ng et al., 2010; Reinhard et al., 2011). Differences in state policies suggest that the proportions of older adults with MH/SU conditions in these settings probably differ across states, and available data indicate that is the case (Grabowski et al., 2009; Zimmerman et al., 2011).

Policies and practices of the nursing home and residential care industries also affect whether older adults with MH/SU conditions will be living in the community, public housing, senior housing, an assisted living facility, or a nursing home. As noted earlier, nursing homes are increasingly admitting people who need short-term, postacute care as opposed to long-term personal care and supervision, and the proportion of residents with dementia among all new admissions has decreased (Fullerton et al., 2009). At the same time, the number of beds in assisted living facilities has increased. As the relevant federal, state, and local government policies and industry policies and practices change over time, the proportions of older adults with MH/SU conditions in various settings are also likely to change.

For purposes of planning for services to meet the needs of older adults with MH/SU conditions and structuring a workforce capable of providing those services, the preceding discussion has three important implications. First, it is clear that substantial numbers of older adults with these conditions live in assisted living, public housing, and senior housing facilities. Two of the studies described earlier show that 26 to 28 percent of older assisted living residents had mental health conditions. These figures do not include residents with dementia and associated behavioral symptoms who probably constitute an additional 20 to 25 percent of older residents. The numbers are smaller, but still significant in senior housing and public housing facilities. Planning for services for older adults with MH/SU conditions should include these people explicitly.

Second, as noted earlier, practical and effective approaches for delivering MH/SU services probably differ for people in congregate-living facilities versus people living in single-family housing in the community. In this context, it should be noted that nursing homes are also congregateliving

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

facilities. The needed skills and competencies for staff working with older adults with MH/SU conditions in nursing homes are probably similar in many ways to the needed skills and competencies for staff working with older adults with these conditions in other congregate-living facilities. The combined number of older adults with MH/SU conditions in these settings suggests that the development of workforce skills and competencies that are practical and effective for congregate-living settings is a high priority.

Finally, it is clear that better information is needed about the proportion and number of older adults with MH/SU conditions who live in assisted living, public housing, and senior housing facilities. Research and analyses conducted to date to categorize and identify assisted living and other residential care facilities for the 2010 National Survey of Residential Care Facilities should allow for the identification of these facilities as a distinct type of congregate-living setting in future surveys of MH/SU conditions. Similar research and analyses are needed to allow for the identification of public housing and senior housing facilities as distinct types of congregate-living settings. Because planning for services and related workforce requirements often occurs at the state level, information about the number and proportions of older adults with MH/SU conditions in all types of congregate-living facilities should be available both nationally and by state.

Older Adults Who Are Dually Eligible for Medicare and Medicaid

In 2008, about 6 million adults age 65 and older were dually eligible for Medicare and Medicaid (Clemans-Cope and Waidmann, 2011). National figures on the proportion of dual eligibles who have mental health conditions vary, depending on the source of the data. The most recent available data come from the 2007 Medicare Current Beneficiary Survey, a large-scale survey of a nationally representative sample of Medicare beneficiaries. These 2007 data show that 19.6 percent of dual eligibles age 65 and older had self- or proxy-reported mental illness.4 An analysis of 2003 data from the same source shows that 20.2 percent of dual eligibles age 65 and older had mental illness (Coughlin et al., 2009), Other analyses show that in the years 2004 through 2006, 26 percent of dual eligibles age 65 and older had one or more mental disorders (MedPAC, 2010) and in 2003, 20 percent of dual eligibles age 65 and older had depression; 2.3 percent had schizophrenia; and 19 percent had other affective and serious mental disorders (Kasper et al., 2010). Finally, an analysis of Medicare, Medicaid, and pharmacy data found that in 2002, 36 percent of dual

____________

4 T. Coughlin, Urban Institute, personal communication, April 30, 2012.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

eligibles age 65 and older had mental disorders, including depressive disorders, bipolar disorder, anxiety disorders, and schizophrenia (Kronick et al., 2009).

Calculations by the committee based on data from the Massachusetts study described earlier in this chapter (Clark et al., 2009) show that in 2005, 38 percent of dual eligibles age 65 and older had SMI or other mental health conditions. Conversely, among older adults with SMI or other mental health conditions, 32 percent were dual eligibles.

Older Veterans

In 2010, there were about 22 million veterans age 18 and older, including about 9 million who were age 65 and older (Census Bureau, 2010c). Not all veterans enroll in the VA health care system, and not all of those who enroll use VA health care services. This section focuses on veterans age 65 and older who enroll in the VA health care system and use VA health care services. The committee’s estimates, presented earlier, of the proportion and number of older adults who have MH/SU conditions include all older veterans, but older veterans who use VA health care services are a special population because they are more likely than other older adults to have MH/SU conditions and more likely to have particular conditions that affect their service needs and the workforce competencies required to meet those needs.

In FY 2011, 4 million veterans age 65 and older were enrolled in the VA health care system, and 2.4 million of those veterans used VA health care services. Table 2-9 shows the prevalence rates and number of older veterans who used VA health care services in FY 2011 and had a diagnosis of an MH/SU condition, one or more conditions, only one condition, two or more conditions, and three or more conditions. The figures include veterans who were living in VA nursing homes and VA domiciliary care facilities, but they do not include veterans who were living in non-VA nursing homes and other facilities, even if the VA was paying for their care in the facility.

As shown in the table, 16 percent of older veterans who used VA health care services had a diagnosis of one or more of the MH/SU conditions. About 11 percent had one diagnosed condition; 4.9 percent had two or more diagnosed conditions, and 1.5 percent had three or more diagnosed conditions. These proportions represent older veterans who have had a diagnostic evaluation and received a clinical diagnosis of one or more MH/SU conditions. In this respect, the figures differ from some of the rates and numbers shown earlier in this chapter that are based on research interviews conducted in population-based surveys and include people who have diagnosed and undiagnosed MH/SU conditions. Veterans

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-9
Prevalence Rates and Number of Veterans Age 65 and Older Who Used VA Inpatient or Outpatient Health Care Services in FY 2011 and Had Diagnoses of Selected MH/SU Conditions

Mental Health and Substance Use Diagnoses

Prevalence Rate (%)

Number of Older Veterans

Mental health diagnoses
   Major depressive disorder

2.3

52,822

   Dysthymia

1.3

31,104

   Other mood spectrum disorders

8.1

189,536

   Panic disorder

0.3

7,863

   Agoraphobia without panic

a

b

   Social phobia

a

b

   Generalized anxiety disorder

1.0

22,267

   Posttraumatic stress disorder

4.3

101,181

   Schizophrenia

0.7

16,447

   Bipolar disorder

0.8

17,650

   Other psychoses

0.8

18,674

Substance use diagnoses
   Alcohol dependence or abuse

2.6

59,801

   Drug dependence or abuse

0.6

14,458

Summary figures
   One or more of the diagnoses

16.0

372,721

   One of the diagnoses

11.1

258,474

   Two or more of the diagnoses

4.9

114,247

   Three or more of the diagnoses

1.5

33,755

a Proportion is less than 0.1 percent.

b Number is less than 500.

SOURCE: Department of Veterans Affairs, FY 2011 data provided to the IOM committee, March 22, 2012.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

ans who receive diagnoses of MH/SU conditions are usually those who come to VA health care providers with more severe symptoms, including veterans who are seeking treatment because of these symptoms.

The rates and numbers in Table 2-9 provide valuable insights about the prevalence of particular MH/SU conditions in this important population. The conditions with the highest prevalence are other mood disorders and PTSD. Other mood disorders are defined as mood or depressive disorders that do not meet the criteria for a DSM-IV-TR diagnosis of major depressive disorder or dysthymia. They include diagnoses of minor depression, affective personality disorder, and depressive disorders that are either superimposed on another mental disorder that is the person’s primary diagnosis or cannot be disaggregated from an underlying physical health or substance use condition.

Behavioral and psychiatric symptoms associated with dementia are not included in Table 2-9. VA projections indicate that about 307,000 veterans age 65 and older with dementia would be enrolled in the VA health care system in 2009, and 185,000 of these veterans would use VA health care services (Cooley and Asthana, 2010). No projection is given for the proportion or number of veterans with dementia who would have behavioral and psychiatric symptoms.

In 2006, about 11,000 veterans of all ages lived in VA nursing homes, including about 8,000 veterans age 65 and older (Lemke and Schaefer, 2010). From 1998 to 2006, the proportion of veterans of all ages who lived in VA nursing homes and had depressive disorders, schizophrenia, PTSD, drug use disorders, and dementia increased, and the proportion that had alcohol use disorders decreased. Among new residents age 65 and older, the proportion with PTSD increased from 1998 to 2006, especially among those born between 1918 and 1925, who were mainly World War II veterans.

A study of 9,618 veterans of all ages who lived in VA nursing homes in 2001 found that 19.6 percent had dementia; 15.1 percent had SMI, defined as schizophrenia, bipolar disorder, and other psychoses; and an additional 2.8 percent had both dementia and SMI (McCarthy et al., 2004). Large proportions of these veterans had behavioral symptoms. An analysis of three types of behavioral symptoms (labeled “physically aggressive,” “verbally disruptive,” and “socially inappropriate”) found that very similar proportions of veterans with dementia, SMI, or both conditions had one or more of the three types of behavioral symptoms (68.7 percent, 65.8 percent, and 67.7 percent, respectively).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

COEXISTING PHYSICAL HEALTH CONDITIONS
AND COGNITIVE IMPAIRMENT

As noted at the beginning of this chapter, many older adults with MH/SU conditions also have one or more physical health conditions, and some have dementia-related cognitive impairment. These coexisting conditions and any medications and other treatments for the conditions can interact with an older person’s MH/SU conditions in ways that make it more difficult to detect, diagnose, treat, and manage any of the conditions. Sometimes it is clear that the person’s mental health or substance use condition or a treatment for the condition directly caused the physical health condition or cognitive impairment, or vice versa. Research and clinical experience have identified some direct causal relationships. Knowledge about these relationships is an important competency for physicians and other health care and MH/SU professionals who work with older adults because that knowledge may allow them to prevent some conditions or at least to recognize a causal relationship and reduce its negative effects on the person. Often, however, there is no direct causal relationship between a person’s mental health or substance use conditions and his or her physical health conditions or cognitive impairment. One condition is not directly causing the other. The conditions simply coexist in the same person. From a workforce perspective, both kinds of situations are important, although probably to a greater or lesser degree for service providers with different responsibilities for detection, diagnosis, treatment, and management of MH/SU conditions in older adults. Although awareness of possible casual relationships is essential for physicians and others who diagnose and prescribe medications for the conditions, awareness that MH/SU conditions, physical health conditions, and cognitive impairment are likely to coexist in older adults is probably most important for direct care workers who often have the first and most frequent opportunities to detect such conditions.

This section presents descriptive information about coexisting MH/SU conditions, physical health conditions, and cognitive impairment in older adults. The text and tables are intended to illustrate the extent of coexisting conditions in settings, such as primary care, home, and community-based care, and hospitals. The information comes from published articles, most of which used the data only to describe the study sample.

Descriptive information about MH/SU conditions, physical health conditions, and cognitive impairment in older adults is usually presented from the perspective that represents the primary interest of particular researchers, clinicians, and others. Those who are primarily interested in MH/SU conditions often describe these conditions as central and refer to the physical health and cognitive conditions as “coexisting.” Conversely, researchers,

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

clinicians, and others who are primarily interested in physical health conditions or cognitive impairment often describe these conditions as central and refer to the MH/SU conditions as “coexisting” (Proctor et al., 2003). The same data can be used to study “coexisting” physical health conditions and cognitive impairment in people with depression and “coexisting” depression in people with physical health conditions and cognitive impairment. For many service providers, it may be less important that particular conditions are considered central or “coexisting” than that the conditions are occurring in the same person.

Table 2-10 shows the proportion of 1,801 community-living adults age 60 and older who had major depression or dysthymia and various physical health conditions (Noel et al., 2004). The people were recruited from primary care settings for a study of a model of depression treatment. Information about their physical health conditions was self-reported.

TABLE 2-10
Proportion of Community-Living Primary Care Patients Age 60 and Older with Depressive Disorders and Selected Physical Health Conditions, N = 1,801

Physical Health Conditions

Prevalence Rate (%)

Chronic lung disease

23

Hypertension

58

Diabetes

23

Arthritis

56

Loss of hearing or vision

55

Cancer, excluding skin cancer

11

Neurological conditions, e.g., epilepsy,
seizures, Parkinson’s disease, stroke

8

Heart disease

28

Gastrointestinal disease

21

Urinary tract and prostate disease

39

Chronic pain

57

SOURCE: Noel et al., 2004.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

As shown in the table, substantial proportions of older adults with major depression or dysthymia also had one or more of the physical health conditions included in the study. The average number of physical health conditions was 3.8. People with severe cognitive impairment were excluded from the study, but 35 percent of people who were included had mild cognitive impairment in addition to their mental health and physical health conditions (Noel et al., 2004).

Another study of 539 community-living adults age 65 and older who were receiving home health care services found that 13.5 percent had major depression and substantial proportions of those individuals also had physical health conditions, including chronic lung disease (23 percent); diabetes (34 percent); metastatic cancer (4 percent); stroke (22 percent); congestive heart failure (30 percent); and peripheral vascular disease (34 percent) (Bruce et al., 2002). About one-fifth (21 percent) of those with major depression also had cognitive impairment.

Anxiety disorders and anxiety symptoms also coexist with physical health conditions and cognitive impairment (Palmer et al., 1997; Wolitzky-Taylor et al., 2010). A study of 377 community-living adults age 60 and older who were receiving in-home care management services found that 27 percent had clinically significant symptoms of anxiety. Of those with anxiety symptoms, 73 percent had five or more physical health conditions; 67 percent had moderate or severe pain; and 11 percent had cognitive impairment (Richardson et al., 2011).

Many older adults with SMI have coexisting physical health conditions (Bartels, 2004). One study of 8,083 male veterans age 60 and older with SMI found that 41 percent had one or more of 18 physical health conditions, including chronic obstructive pulmonary disease (18 percent); hypertension (36 percent); diabetes (21 percent); arthritis (9 percent); cancer (7 percent); stroke (5 percent); ischemic heart disease (14 percent); congestive heart failure (6 percent); and peripheral vascular disease (5 percent). Seven percent also had alcohol or drug use disorders (Kilbourne et al., 2005).

Older adults hospitalized for mental health conditions often have coexisting physical health conditions (Woo et al., 2003; Zubenko et al., 1997). A study of 195 adults age 60 and older who were hospitalized for major depression found that 75 percent also had one or more physical health conditions, including chronic obstructive pulmonary disease (7 percent), hypertension (59 percent), diabetes (22 percent), arthritis (27 percent), heart disease (25 percent), congestive heart failure (10 percent), thyroid conditions (12 percent), and Parkinson’s disease (9 percent) (Proctor et al., 2003). One-quarter of the people had three or more of the conditions. The researchers note that the study sample included only older adults who were discharged from the hospital to home and that older

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

adults discharged to a nursing home probably had more coexisting physical health conditions.

Some older adults hospitalized for physical health conditions also have mental health conditions (Banta et al., 2010; Koenig and George, 1998). A study of 1,007 male veterans of all ages hospitalized for heart disease, cancer, or other medical conditions found that 18 percent had one or more MH/SU conditions, including anxiety disorders (11 percent), depressive disorder (7 percent), alcohol abuse disorder (5 percent), and schizophrenia (0.8 percent) (Booth et al., 1998).

Lastly, a study of 18,939 community-living adults age 65 and older who were enrolled in two Michigan home care programs found high levels of physical and mental health conditions and cognitive impairment (Li and Conwell, 2007). The programs provide personal care, homemaker, and other supportive services to help individuals who are eligible for nursing home placement to remain at home instead. Information about the older adults was obtained in structured in-person interviews conducted by a nurse and social worker in the person’s home. Table 2-11 shows only those physical health conditions that were present in 20 percent or more of the people.

As shown in the table, large proportions of the older adults had one or more of the physical health conditions included in the study. The average number of conditions was 5.3. Nearly half of the people (47.6 percent) experienced pain every day, including 25.1 percent with severe daily pain; more than 40 percent had mental disorders; about one-quarter had other mental health symptoms; and 43 percent had cognitive impairment.

The preceding text and tables illustrate the complex array of MH/SU conditions, physical health conditions, and cognitive impairment that service providers may encounter in various care settings. Some of the conditions are causally related, and some simply coexist in the same older person. Analysis of service needs and the workforce competencies required to meet those needs must take into account the high rates of coexisting physical health conditions and cognitive impairment in older adults with MH/SU conditions.

IMPACT OF MH/SU CONDITIONS

MH/SU conditions in older adults are associated with a wide range of negative effects, including emotional distress, functional disability, reduced physical health, increased mortality, suicide, high rates of hospitalization and nursing home placement, and high costs. Much of the published research about these negative effects in older adults pertains to depression, including many studies that compare the negative effects of DSM-IV-TR depressive disorders versus depressive symptoms that do not

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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TABLE 2-11
Proportion of Community-Living Adults Age 65 and Older with Selected Physical Health Conditions, Mental Health Conditions, and Cognitive Impairment in Two Michigan Home Care Programs, N = 18,939
a

Physical Health Conditions

Prevalence Rate (%)

   Chronic lung disease, including emphysema and asthma

27.0

   Hypertension

69.2

   Diabetes

32.9

   Arthritis

73.3

   Stroke

27.0

   Coronary artery disease

29.1

   Cardiac dysrhythmia

22.2

   Congestive heart failure

35.0

Pain
   Moderate daily pain

22.5

   Severe daily pain

25.1

Mental disorders
   Depression

32.9

   Anxiety

18.8

   Schizophrenia

0.6

Other mental health conditions
   Depressive symptoms

24.5

   Suicidal ideation in the past 30 days

1.2

   Suicide attempts in the past 12 months

0.3

Cognitive impairment
   Mild or moderate cognitive impairment

34.1

   Severe cognitive impairment

9.0

a Some data derived from L. W. Li, University of Michigan School of Social Work, Ann Arbor, MI, unpublished data provided to the IOM committee, March 12, 2012.

SOURCE: Li and Conwell, 2007.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

meet the criteria for a DSM-IV-TR diagnosis of depression. Less research is available about negative effects of the other MH/SU conditions identified by the IOM committee, although many studies address the negative effects of some of these conditions, for example, bipolar disorder and schizophrenia, in people under age 65.

Anecdotal evidence and a relatively small number of studies indicate that families of older adults with MH/SU conditions experience negative effects of the conditions in terms of their own emotional distress, psychological and physical consequences of caregiving, and out-of-pocket costs. These negative effects have been studied extensively in families of older adults with behavioral and psychiatric symptoms associated with dementia. Negative effects on families of people with other MH/SU conditions have been studied less in families of older adults than in families of younger people with the conditions.

This section provides a brief overview of findings from available research on emotional distress and health-related quality of life, mortality, suicide, and costs. Many of the available studies are based on cross-sectional data and therefore cannot demonstrate a causal relationship between MH/SU conditions and negative effects. In addition, as discussed previously, MH/SU conditions, physical health conditions, and cognitive impairment frequently coexist in older adults, and it is difficult to disentangle the relative contributions of these conditions to the negative effects.

Emotional Distress and Health-Related Quality of Life

Many older adults with MH/SU conditions experience severe emotional distress. It has been noted, however, that some older adults are unwilling to report this effect. In addition, some older adults may not experience the emotional effects that are usually associated with an MH/SU condition. For example, as described earlier in this chapter, some older adults who have major depressive disorder do not experience sadness.

Three surveys of nationally representative samples of community-living adults regularly include questions about emotional distress. The BRFSS survey asks, “Now, thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” In 2006, 6.5 percent of community-living people age 65 and older (about 2.5 million people in 2010) indicated that they experienced these symptoms on 14 or more of the previous 30 days (CDC and National Association of Chronic Disease Directors, 2008).

The NHIS asks how often in the past 30 days the respondent has felt “so sad that nothing could cheer you up”; “nervous”; “restless or fidgety”;

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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“hopeless”; “that everything was an effort”; or “worthless.” In 2010, 2.3 percent of community-living people age 65 and older (about 900,000 people) had scores indicating frequent, serious distress (NCHS, 2011d). Using the same questions, the 2010 NSDUH found that 2.1 percent of community-living adults age 65 and older (about 800,000 people) reported frequent, serious distress (CBHSQ, 2012e).

Studies that have used structured assessments of quality of life or health-related quality of life also show that MH/SU conditions, including depressive disorders, depressive symptoms, generalized anxiety disorder, and substance use disorders, are associated with reduced health-related quality of life (Booth et al., 2001; Chachamovich et al., 2008; Porensky et al., 2009; Spitzer et al., 1995). One study of 134 adults age 58-104 with dementia who were living in assisted living facilities found that behavioral and psychiatric symptoms were associated with reduced quality of life (Samus et al., 2005).

Mortality

People of all ages with MH/SU conditions experience higher mortality rates than other people without these conditions. Their higher mortality has been attributed to many factors, including poor compliance with prescribed medical treatments for physical health conditions; toxic effects of medications prescribed for their MH/SU condition; negative health behaviors, such as excessive use of alcohol and drugs, smoking, and inactivity; poor-quality medical care; poverty; lack of health insurance; and lack of coordination in the medical and specialty MH/SU systems (Druss and von Esenwein, 2006).

•   A 2006 report of the National Association of State Mental Health Program Directors indicates that people with SMI die 25 years earlier than the general population and that recent state studies show that premature mortality is increasing (Parks et al., 2006).

•   An analysis of data from the New Haven ECA site shows that survey participants age 55 and older with major depressive disorder were four times more likely than other survey participants to die in a 15-month period (Bruce and Leaf, 1989).

•   An analysis of data on public mental health clients in eight states found that they had higher mortality rates and died at a younger age than the general population. Those with major mental illnesses were more likely to die than those with less severe mental illnesses and more likely to die at a younger age (Colton and Manderscheid, 2006).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

•   An analysis of data on people interviewed for the 1989 NHIS and followed for 17 years found that those with a mental disorder died an average of 8.2 years earlier than other survey participants (Druss et al., 2011).

Suicide

In 2007 (the most recent data available), there were 5,421 suicides among adults age 65 and older, including 4,569 men and 852 women (Xu et al., 2010). Suicide rates for men increased with age from 22.4 per 100,000 men age 65-69 to 41.8 per 100,000 men age 85 and older, the highest rate for any age group (Crosby et al., 2011). Suicide rates for women were lower and decreased from 4.5 per 100,000 women age 65-74 to 3.1 per 100,000 women age 85 and older.

Costs

National figures on the costs of MH/SU conditions in older adults vary depending on which older adults, conditions, services, and payers are included. The 2009 Medical Expenditure Panel Survey (MEPS) found that 7.4 million adults age 65 and older received services for mental disorders (AHRQ, 2009a) at a cost of $17.1 billion (AHRQ, 2009b), making mental disorders the eighth most costly condition for adults age 65 and older in the United States in 2009.

The MEPS includes community-living people and excludes people living in nursing homes, prisons, or jails. Mental disorders are self-reported and include substance use conditions. Survey respondents identify which services they received for the reported conditions. Services included in the $17.1 billion for 2009 are hospital, emergency department, and outpatient services, physician and other medical provider office visits, home health services, other home care services, and prescribed medications. Medical equipment and supplies, ambulance services, eyeglasses, dental care, and over-the-counter medications are not included.

The $17.1 billion figure from MEPS includes expenditures by all payers. In 2009, Medicare paid more than half (52.5 percent) of the cost of services for mental disorders for adults age 65 and older. The remaining 47.5 percent was paid by Medicaid (11.4 percent), private insurance (11.7 percent), out-of-pocket (18.3 percent), and other sources, including the VA, state and local health departments, state programs other than Medicaid, and community and neighborhood clinics (6.1 percent) (AHRQ, 2009c).

Medicare reimbursement data for 2009 provide a different perspective on the costs of MH/SU services for older adults. Table 2-12 shows 2009

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Medicare reimbursements for MH/SU services for beneficiaries age 65 and older who were enrolled in fee-for-service Medicare.

As shown in the table, Medicare reimbursements for MH/SU services for older fee-for-service Medicare beneficiaries amounted to $2.4 billion in 2009. Most of the $2.4 billion (93 percent) was for mental health services. The remaining 7 percent was for alcohol use services (4 percent) and drug use services (3 percent). The $2.4 billion total represents 1 percent of Medicare reimbursements for all covered services for Medicare fee-for-service beneficiaries in 2009.

The large gap between the $17.1 billion figure from MEPS and the $2.4 billion figure based on Medicare reimbursement data reflects differences in the people, conditions, services, and payers included in each figure.

•   The Medicare reimbursement data pertain to all community-living adults and nursing home residents age 65 and older who were enrolled in fee-for-service Medicare in 2009 but exclude about 9.8 million Medicare beneficiaries (25 percent of all Medicare beneficiaries age 65 and older) who were enrolled in Medicare Advantage health plans (CMS, 2010). In contrast, Medicare Advantage enrollees are included in the MEPS figure.

•   The Medicare reimbursement data include services for which an MH/SU condition is listed as the primary diagnosis on the Medicare claim. In contrast, the MEPS survey respondent identifies the services received for MH/SU conditions, and no distinction is made between primary and secondary diagnoses.

•   The Medicare reimbursement data include services that are covered by Medicare, including ambulance services and medical equipment, but exclude prescription drugs, which account for $6.4 billion of the Medicare costs included in the MEPS figure. The MEPS figure also includes Medicare copayments and deductibles and nursing home and home care services that are not covered by Medicare.

•   The Medicare reimbursement data include only Medicare costs, whereas the MEPS figure includes costs to all payers, including Medicare, Medicaid, private insurance, out-of-pocket, and other payers.

USE OF MH/SU SERVICES BY OLDER ADULTS

The kinds of services required to meet the needs of older adults with MH/SU conditions include detection, diagnosis, treatment, ongoing management, and monitoring. To the extent that older adults receive these kinds of services, the services are provided by a bewildering array of

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-12
Medicare Reimbursement for Mental Health and Other Substance Use Services for Fee-for-Service Beneficiaries Age 65 and Older, 2009

MH/SU Service Providers Medicare Reimbursement ($ Millions)
All MH/SU Services Mental Health Services Only Alcohol Use Services Only Drug Use Services Only
All providers 2,440 2,259 108 73
Hospitals 1,558 1,413 85 60
• Community hospitals 1,267 1,136 75 57
  °  Inpatient care 935 818 63 53
   -Specialty MH/SU unit 694 680 8 5
   -General unit 241 138 55 48
  °  Outpatient care 319 306 11 3
   -Specialty MH/SU unit 3 3 0 0
   -General unit 317 303 11 3
Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×
• Psychiatric hospitals 291 278 10 3
  °  Inpatient care 214 202 9 3
  °  Outpatient care 77 76 0 0
Nursing homes 174 160 12 2
Home health care 119 117 1 1
Physicians 294 282 7 5
  • Psychiatrists 203 200 2 1
  • Other physicians 90 81 5 4
Psychologists, nurses, social workers, counselors, other nonphysician MH/SU service providers, and other professionals 245 243 1 0
Laboratories 13 9 1 4
Ambulance services 50 46 2 2

SOURCE: Thomson Reuters, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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organizations and individuals. Chapter 3 describes the geriatric MH/SU workforce, focusing primarily on the education, training, credentials, and competencies of the many types of individual providers who are or could be part of the workforce that provides the services. This section describes the types of organizations and settings that provide or could provide MH/SU services for older adults. It discusses older adults’ attitudes and beliefs about using MH/SU services and reviews the available data about their past and current use of these services.

The available information about older adults’ use of MH/SU services is not sufficient to support a credible analysis of the number and proportion of older adults that need but do not use MH/SU services. Available data suggest, however, that there is substantial unmet need.

Organizations and Settings That Provide MH/SU Services

From a national perspective, the organizations and settings that provide MH/SU services for older adults can be categorized in various ways. In Box 2-5, these organizations and settings are categorized in six broad types and a catch-all “other” type, based on their primary focus. The categorization also differentiates: (1) general medical care, residential, and community social service organizations and settings intended to serve people who do and do not have MH/SU conditions, and (2) specialty mental health and substance use organizations and settings intended to serve only people who have MH/SU conditions. From the federal government perspective, the organizations and settings included in Box 2-5 could also be categorized on the basis of the federal agency or agencies with primary administrative responsibility for the services. Alternatively, the organizations and settings could be categorized on the basis of their main sources of funding (Medicare, Medicaid, private insurance, out-of-pocket payments, federal block grants, state funds, and other).

From a state perspective, the organizations and settings listed in Box 2-5 are often categorized differently, with a stated designation of some organizations and settings as part of the “public mental health system.” Every state has a State Mental Health Agency (SMHA) that is responsible for the delivery of public mental health services. The public and private organizations and settings operated and/or funded by the SMHA are generally considered to comprise the state’s public mental health system. In 2009, SMHAs across the country operated and/or funded nearly 20,000 public and private mental health organizations, settings, and providers, including 212 state psychiatric hospitals, 70 private psychiatric hospitals, 440 general hospitals with a separate psychiatric unit, 59 nursing homes and intermediate care facilities for mental illness (ICF-MI), and 18,847 community mental health centers and providers (SAMHSA, 2009). In

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

2008, 5 percent of the 6.3 million people of all ages who received SMHA-operated or SMHA-funded mental health services were age 65 and older (about 315,000 people) (SAMHSA, 2009).

States differ considerably in terms of the mental health organizations and settings that are operated or funded by the state’s SMHA versus other state agencies, for example, agencies with primary responsibility for Medicaid, criminal justice and corrections, and housing (NRI, 2009). States also differ in terms of whether the SMHA has administrative responsibility for the state’s substance use services. In 2009, SMHAs in 27 states had administrative responsibility for substance use services (SAMHSA, 2009). Responsibility for these services was located in another agency in the remaining states.

During the recent financial depression, many states have reduced funding for their SMHA. For FY 2010, 9 to 20 SMHAs reported cuts in state funding for various mental health services, including inpatient long-term care (20 states), inpatient acute care (19 states); clinic services (12 states), and other inpatient and day treatment services (9 states) (CBHSQ, 2012a). Eight to 17 SMHAs reported anticipated cuts in funding for the same services in FY 2011.

States’ define the eligibility criteria for services operated or funded through their public mental health system, but all states include services for people with SMI, and states generally prioritize services for people with low income and those who are uninsured or have only Medicaid (Garfield, 2011). National data show that SMHAs operate or fund mental health services for disproportionate numbers of older people in racial and ethnic minority groups. In 2008, the population rates for use of mental health services operated or funded by SMHAs were higher for black, Hispanic/Latino, and Native American people age 65 and older (11.8, 10.6, and 8.6 persons per 1,000 in the population, respectively) than for whites and Asian Americans (6.3 and 4.9 persons per 1,000, respectively) (SAMHSA, 2009). Moreover, in at least some states, the SMHA operates or funds mental health services for a disproportionate number of older people living in rural versus urban areas (Karlin and Norris, 2006). Recent reductions in state funding for SMHAs raise concerns about the current and future capacity of SMHAs to provide mental health services for these vulnerable groups of older adults.

From the perspective of a county or local government, the organizations and settings listed in Box 2-5 might be categorized differently than they are usually categorized from either a national or state perspective. Especially in smaller jurisdictions, these organizations and settings might be thought of less in broad categories and more as unique local agencies that provide various combinations of mental health, substance use, and general medical, residential, and community-based aging and social

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-5
Types of Organizations and Settings That Provide
Some MH/SU Services for Some Older Adults

General medical care organizations and settings. Includes thousands of public and private acute care hospitals; emergency departments; primary medical care settings, such as individual physician offices, group medical practices, ambulatory care clinics, community health centers (CHCs), federally qualified health centers (FQHCs), and rural health centers; and Medicare-certified home health care agencies. The main focus of these organizations and settings is medical and medically related care for physical health conditions. All of these organizations and settings provide care for older adults, and most of them provide some MH/SU services for some older adults.

General residential care organizations and settings. Includes nursing homes; assisted living and other residential care facilities; and congregate-living settings, such as senior housing and public housing facilities. The main focus of these organizations and settings is housing and services ranging from skilled nursing care, rehabilitative services, and extensive assistance with personal care in nursing homes to health-related and supportive services in residential care facilities and congregate-living settings. All of these organizations and settings provide services for older adults, and many of them provide some MH/SU services for some of their older residents.

Aging network agencies and other social service organizations and settings. Includes Area Agencies on Aging (AAAs); senior centers; adult day centers; and many other community agencies that provide health-related and social services, such as personal care, homemaker, and chore services, congregate and home-delivered meals, transportation, information, referrals, and counseling about services and benefits, care management, family caregiver support, and respite care. The main focus of these organizations and settings is supportive services to help individuals remain at home and as functionally independent as possible. Nearly all of the organizations and settings provide services for older adults, and many of them provide some MH/SU services for some older adults.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Specialty mental health organizations and settings. Includes public and private psychiatric hospitals; residential mental health treatment centers; day treatment centers; outpatient mental health clinics; community mental health centers; mental health group homes; individual and group mental health practices that provide psychiatric, psychological, and counseling services; crisis and emergency mental health organizations; lay- and volunteer-led organizations that provide mental health support and self-help services; and specialty managed care organizations that provide mental health services through “carve-out” arrangements with insurers and other payers. All of these organizations and settings provide mental health services, and many of them provide some mental health services for some older adults.

Specialty substance use organizations and settings. Includes public and private residential and outpatient substance use treatment centers, day treatment centers, substance use group homes, crisis and emergency substance use organizations, lay- and volunteer-led organizations that provide substance use support and self-help services, and specialty managed care organizations that provide substance use services through “carve out” arrangements with insurers and other payers. All of these organizations and settings provide substance use services, and some of them provide some substance use services for some older adults.

Veterans Affairs (VA). The VA provides a wide array of medical, mental health, substance use, residential, and home and communitybased services for veterans who enroll in the VA health care system. At its medical centers, community-based outpatient centers, and other facilities and through contracts with other organizations, the VA provides all these services for some older veterans with MH/SU conditions.

Other. Includes adult correctional facilities, housing organizations, settings that serve homeless people, adult protective service agencies, public health agencies, and organizations and settings funded by the Indian Health Service.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

services, using funding from an array of federal, state, and local government sources, private insurance, and donations from philanthropic organizations and individuals. A local Area Agency on Aging (AAA), for example, might be thought of less as part of a national network of aging services agencies and more as a unique community agency that provides information and referrals, care management, home-delivered meals, and assessments for Medicaid-funded home- and community-based services, using many funding sources in addition to the federal Older Americans Act. In many counties and local jurisdictions, the police department and ambulance service(s) might also be thought of as organizations that provide MH/SU services in crisis and emergency psychiatric situations.

Differences in the way organizations and settings that provide MH/SU services are categorized at the national, state, county, and local government levels make it difficult to create a coherent description of these organizations and settings. More importantly in the context of this report, differences in the way the organizations and settings are categorized at different levels of government make it very difficult to design and implement comprehensive initiatives to address problems in the care of older adults with MH/SU conditions. Such initiatives and the regulatory and financing policies to support them generally target types of organizations and settings that reflect the categories used at the level of government that develops the initiative. Yet, federal government initiatives that target, for example, organizations, settings, and providers that receive Medicare payments and may include training, credentialing, or other workforce requirements will apply to some but not all organizations, settings, and providers that are part of the state-defined public mental health system or the array of community agencies that are considered by local governments to be providing MH/SU services. Likewise, state government initiatives that target organizations, settings, and providers that comprise the state’s public mental health system will apply to some, but not all organizations and settings categorized as providing MH/SU services at the federal or local level.

As noted in Box 2-5, the VA provides MH/SU services for veterans enrolled in the VA health care system, which is the largest integrated health care system in the United States. VA health care system integration, which includes common categorizations of types of services, settings, and providers at the national, regional, and local levels as well as an advanced electronic medical record system that is accessible across all levels, greatly facilitates the design and implementation of comprehensive, systemwide initiatives to address medical and medically related conditions, including MH/SU conditions. Box 2-6 describes the VA’s systemwide programs to prevent suicide in veterans of all ages. A recent report funded by SAMHSA described these suicide prevention programs as “perhaps the

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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most comprehensive suicide prevention initiative in history” (Suicide Prevention Resource Center and SPAN USA, 2010).

Older Adults’ Attitudes and Beliefs About Using MH/SU Services

It is sometimes said that older adults do not use MH/SU services because of stigma associated with the conditions and related services. Their greater tendency to use MH/SU services provided in general medical, residential, and home- and community-based settings versus specialty MH/SU settings is sometimes also attributed to perceived stigma. Available data support the concept that substantial proportions of older adults perceive stigma associated with MH/SU conditions and related services, but the data also identify other attitudes and beliefs, some of which may have an even greater impact on older adults’ use of MH/SU services.

One study of more than 600 community-living adults age 60 and older who were receiving health-related and social services from a public long-term care agency assessed their attitudes and beliefs about mental health service use and compared the attitudes and beliefs of those who had depression (either a DSM-IV-TR depressive disorder or depressive symptoms) and those who did not (Morrow-Howell et al., 2008). The study found that more than 90 percent of both groups of older adults said people with mental or emotional problems should seek professional help. Nearly the same proportions said they would seek treatment if they had a mental or emotional problem (89 percent of those who had depression and 94 percent of those who did not). On the other hand, more than 80 percent of both groups said the cost of treatment would be more than they could afford, and only 41 percent said they knew where to obtain treatment. Relatively small proportions said their family would be upset if they knew the person was receiving help for a mental or emotional problem (16 percent of those who had depression and 18 percent of those who did not). Even smaller proportions said that someone in their family would object if the person wanted to go for treatment of a mental or emotional problem (11 and 7 percent, respectively) or that they would avoid treatment of a mental or emotional problem because friends might find out (5 and 1 percent, respectively). Nearly one-third of both groups said they believed that “you should always handle mental and emotional problems by yourself.” Nearly one-quarter (24 percent) of those who had depression and 17 percent of those who did not have depression said that mental and emotional problems will get better by themselves.

The findings from this study are reflected to varying degrees in findings from surveys conducted in national, population-based samples. The National Comorbidity Survey Replication (NCS-R) (see Box 2-2) found that more than 80 percent of community-living older adults had positive

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-6
Suicide Prevention Programs in the VA

Suicide prevention is a major national priority of the VA, and the agency has implemented a comprehensive array of systemwide suicide prevention programs. These programs include suicide monitoring and risk assessment, a national suicide crisis line, full-time suicide prevention coordinators in every VA medical center, and electronic medical record flags to notify clinicians of suicide risk.

Suicide monitoring and risk assessment. The VA conducts ongoing comprehensive, systemwide suicide monitoring and risk assessment for veterans who use VA health care services. Findings from suicide monitoring activities show that in fiscal years 2000 and 2001, age- and sex-adjusted suicide rates among VA users were elevated in comparison with rates in the general U.S. population, with a standardized suicide ratio of 1.66 for male veterans and 1.87 for female veterans (McCarthy et al., 2009). Trends in suicide rates among VA users show a slight reduction between fiscal years 2000 and 2007, with male veterans age 30 to 64 being at the highest risk of suicide (Blow et al., 2012). Risk assessment activities have identified various factors associated with elevated suicide risk, including recent psychiatric hospitalizations, the start of antidepressant medication, and dosage changes (Valenstein et al., 2009). Mental disorders have been found to be strongly associated with elevated risk of suicide. For example, suicide risk for male veterans with bipolar disorder was found to be three times higher than for other male veterans (Ilgen et al., 2010). Suicide risk has also been found to be elevated for veterans living in rural areas, even after adjusting for clinical factors and distance to nearest VA mental health providers (McCarthy et al., 2012). These and other findings from the VA’s ongoing suicide monitoring and risk assessment activities are routinely shared with VA administrators

help-seeking attitudes: 86 percent of the survey respondents age 65-74 and 82 percent of those age 75 and older said they would seek professional help if they had serious emotional problems (Mackenzie et al., 2008). Likewise, 82 percent of those age 65-74 and 76 percent of those age 75 and older said they would be comfortable talking about personal problems with a professional. Most of the respondents age 65 and older also had positive treatment beliefs: more than 70 percent said they believed that half or more of people who see a professional for serious emotional

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

at all levels, and medical and mental health clinicians and other frontline service providers.

National suicide crisis line. In 2007, the VA established a national 24/7 crisis hotline that has received more than 600,000 calls and made more than 21,000 life-saving rescues. Initially named the National Veterans Suicide Prevention Hotline, the call line was renamed as the Veterans Crisis Line to reduce perceived stigma and facilitate use by veterans and their families and friends. In 2009, VA added an anonymous online chat service that has been used by more than 50,000 people.

Suicide prevention coordinators. The VA has placed suicide prevention coordinators at all medical centers. The coordinators have a fulltime commitment to suicide prevention activities. They collaborate with VA mental health clinicians to support suicide prevention efforts for individuals at high risk and to ensure that these individuals receive increased monitoring and enhanced care. Specific activities include tracking and reporting on veterans found to be at high risk for suicide and those who have attempted suicide; training staff who have contact with veterans so that they know how to get immediate assistance if veterans express any suicide plan or intent; collaborating with community organizations and partners and providing training to their staff who have contact with veterans; and providing consultations to providers regarding resources for suicidal individuals.

Clinical flags for high-risk veterans. The VA uses electronic medical record flags to identify veterans at high risk for suicide. High risk is defined by various factors, including a history of suicide attempts and recent discharge from an inpatient mental health unit. For veterans identified as having high risk for suicide, VA clinicians can contact the suicide prevention coordinator about services and need for closer monitoring. Clinicians are also trained to recognize that absence of a positive flag does not imply the veteran is not at risk for suicide.

problems are helped. Nevertheless, 31 percent of those age 65-74 and 26 percent of those age 75 and older said they would be embarrassed if their friends knew they were getting professional help for an emotional problem.

The 2001 NSDUH found that among community-living older adults with mental health conditions, only 10 percent reported receiving any mental health services (Karlin et al., 2008). The two primary reasons older adults gave for not using mental health services were (1) not knowing

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

where to go for services (28 percent), and (2) lack of affordability (19 percent). Less than 1 percent said they needed but did not receive mental health services in the previous year. On the other hand, older adults who used mental health services were at least as likely as younger adults who used the services to say the services benefited them.

Several studies have found that substantial proportions of older adults with mental health conditions do not perceive a need for mental health services and are not interested in using such services. One study of more than 9,500 adults with probable mental disorders found that only 28 percent of those age 65 and older perceived a need for mental health services, compared with higher proportions of those under age 65 (49 percent of those age 18-29 and 43 percent of those age 30-64) (Klap et al., 2003). Another study of 268 community-living people age 57-97 found that more than half of those with depressive symptoms were not receiving any mental health services, and only 34 percent of them expressed interest in receiving such services (Cohen-Mansfield and Frank, 2008).

Older people differ in their beliefs about the causes of mental health conditions. One study of 90 older people with depression found that 28 percent attributed the condition to “old age” rather than to an illness. Those who attributed their depressive symptoms to old age were four times less likely than those who attributed the symptoms to an illness to say that it is important to discuss such symptoms with a doctor (Sarkisian et al., 2003). A recent analysis of the beliefs of white, black, Hispanic/ Latino, and Asian American older adults about the causes of mental health conditions found significant variation among groups that is likely to affect help-seeking behaviors (Jimenez et al., 2012).

Interviews and focus groups conducted in San Diego with 165 mental health service providers, family caregivers, consumers age 55 and older, and other older adults identified many factors associated with unmet needs for mental health services for older adults (Palinkas et al., 2007). Of the 66 consumers age 55 and older and other older adults, more than 60 percent were from racial and ethnic minority groups. Factors identified by the consumers and other older adults included the following:

•   stigma (63 percent);

•   lack of information about available services (50 percent);

•   lack of age-appropriate and culturally and linguistically appropriate services, including translators in mental health settings (44 percent);

•   lack of transportation to services (38 percent); and

•   lack of money or insurance to pay for services (25 percent).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

As noted earlier, the available research shows that many older adults perceive stigma associated with MH/SU conditions and MH/SU services. Beliefs and attitudes, such as that mental and emotional problems will get better by themselves and that it is better to handle these problems by oneself, could be thought of as separate from, caused by, or resulting in perceived stigma. Likewise, lack of awareness of one’s mental health condition and lack of interest in receiving services for a mental health condition could be thought of as separate from, contributing to, or caused by perceived stigma. Other factors, such as lack of information about available services, lack of age- and culturally and linguistically appropriate services, lack of transportation, and lack of money or insurance to pay for services, undoubtedly reflect current reality. In the context of older adults’ positive beliefs about the importance of obtaining mental health services and the likely effectiveness of such services, however, these other factors interact with perceived stigma and related attitudes and beliefs to reduce older adults’ willingness to use MH/SU services. Professional and other service providers who interact with older adults in specialty MH/SU, general medical, residential, and home- and community-based care settings should be aware of the array of attitudes, beliefs, and other factors that influence older adults’ decisions about MH/SU service use and able to identify and implement approaches to reduce such barriers to needed services.

Older Adults’ Use of MH/SU Services

Comprehensive information is not available about the proportion or number of older adults with MH/SU conditions that use any of the kinds of MH/SU, and much less information is available about detection than about diagnosis, treatment, ongoing management and monitoring. In general, by the time an older adult uses services provided by specialty MH/SU organizations and settings, the person’s MH/SU condition has already been detected by someone and may have been diagnosed. The MH/SU services needed by the person at that point are diagnosis, if not already completed, treatment, ongoing management, and monitoring. In contrast, MH/SU conditions in older adults may not have been detected in general medical, residential, and home- and community-based care settings. From a workforce perspective, it is important to consider this fundamental difference in needed MH/SU services by type of setting and its implications for training and workforce competencies.

Studies of detection of MH/SU conditions in older adults in general medical, residential, and home- and community-based care settings indicate that the conditions are frequently not detected (see, e.g., Brown et al., 2003; Rosenblatt et al., 2004). Such studies are difficult to conduct

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

because they require both a process to determine which older adults have an MH/SU condition and a process to determine whether the condition has been detected. Moreover, study findings differ, depending on the type of setting, particular provider, and how “detection” is measured, for example, by a notation in a person’s medical record, a diagnostic code on a billing or claim form, the report of the person or a family member that a physician has said the person has the condition, or the report of a service provider who has worked with the person. Nevertheless, frequent calls to implement screening for various MH/SU conditions in general medical, residential, and home- and community-based care settings reflect many service providers’ experience that the conditions are often missed.

A convincing body of evidence shows that older adults are less likely than younger adults to receive treatment for their MH/SU conditions (Dixon et al., 2001; German et al., 1985; Karlin et al., 2008; Klap et al., 2003; Shapiro et al., 1984; Wang et al., 2000, 2005) and that they are less likely than younger adults to receive MH/SU treatment in a specialty setting and more likely to receive treatment in general medical, residential, and home- and community-based service care settings (German et al., 1985; Shapiro et al., 1984; Wang et al., 2005). Large-scale, population-based surveys conducted over the past 30 years in the United States have found that only small proportions of older adults with MH/SU conditions receive any services for these conditions. Most of the surveys do not include institutionalized people; thus, they do not include people living in nursing homes. The surveys differ somewhat in the MH/SU conditions and kinds of services they include. They all use structured diagnostic interviews to identify people with MH/SU conditions but generally do not ask whether the people have received a diagnostic evaluation or a formal diagnosis of the condition.

From 1980 to 1984, the National Institute of Mental Health Epidemiologic Catchment Area (ECA) Program conducted interviews with more than 18,500 adults age 18 and older, including 5,700 adults age 65 and older, in five sites across the country. The survey found that about one-third of adults age 18 and older who had a MH/SU condition received any treatment for the condition in a 1-year period (Narrow et al., 2000; Regier et al., 1993), and those age 65 and older were less likely than those under age 65 to receive treatment (Shapiro et al., 1984). In the Baltimore site, where older adults were oversampled, only 1 percent of adults age 65-74 with MH/SU conditions and no one age 75 and older with these conditions had received treatment in a specialty setting, compared with 17 percent of adults age 18-64 with the conditions (German et al., 1985). About the same proportions of adults age 18-64 and 65-74 with MH/SU conditions (17 percent and 18 percent, respectively) said they had discussed emotional problems with a primary care provider during a general

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

medical care visit, but only 10 percent of those age 75 and older said they had such discussions.

Two studies conducted in the late 1990s found that older adults with mental health conditions were less likely than younger people to receive treatment for the conditions:

•   The 1996 Midlife Development in the United States (MIDUS) study used a telephone interview and mail questionnaire to assess use of mental health treatment in a nationally representative sample of 3,000 adults age 25-74; the study found that adults age 65-74 with mental health conditions were 40 percent to 140 percent less likely than those under age 65 with the conditions to receive any treatment for the conditions (Wang et al., 2000).

•   The 1997-1998 Health Care for Communities (HCC) household study used a telephone interview and mailed questionnaire to assess use of mental health treatment in a stratified random sample of 9,585 adults age 18 and older. The study found that adults age 65 and older with mental health conditions were less likely than those age 30-64 with the conditions to receive mental health treatment (53 versus 60 percent, respectively), but they were more likely to receive mental health treatment than adults age 18-29 (53 percent versus 49 percent, respectively) (Klap et al., 2003). Among adults who received any mental health treatment, only 7 percent of older adults, compared with 18 percent of adults age 18-29 and 26 percent of those age 30-64 received treatment in a specialty mental health setting. Fewer older adults reported being asked by a primary care provider if they felt tense or anxious (15 percent compared with 23 percent for younger people); fewer older adults reported that a primary care provider had spent 5 minutes or more on mental health counseling (4 percent compared with 7 percent to 8 percent for younger people); and only 1 percent of older adults reported that a primary care provider had referred them to a mental health specialist in the past year for evaluation or treatment, compared with 3 percent of younger people.

Large-scale surveys conducted in the early 2000s continued to find relatively low use of MH/SU treatment by older adults. As noted earlier, the 2001 NSDUH found that only 10 percent of adults age 65 and older with mental health conditions received MH/SU treatment, compared with 25 percent of younger adults with the conditions (Karlin et al., 2008). Among those with SMI, the difference was greater (9 percent for adults age 65 and older compared with 32 percent for people under age 65).

One analysis of data from the NCS-R, which was conducted in 2001-

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

2002, found a lower overall rate of treatment for older adults with any of the MH/SU conditions included in the study and a lower likelihood of receiving treatment in a specialty setting for older adults (Wang et al., 2005). Another analysis of data from the three surveys that are part of the CPES conducted from 2001 to 2003, found that 66 percent of older adults with major depressive disorder and 72 percent of older adults with anxiety disorders had not received any treatment for these conditions in the previous year (Garrido et al., 2011). Importantly, only 50 percent of older adults with major depressive disorder and only 43 percent of those with anxiety disorders perceived a need for treatment; of those who perceived a need for treatment, 17 percent did not seek treatment at all, and 21 percent delayed seeking treatment for at least 4 weeks.

As noted earlier, it is sometimes said that the greater tendency of older adults to use MH/SU services provided in general medical, residential, and home- and community-based settings versus specialty MH/SU settings is due to perceived stigma. Other interrelated factors probably also contribute to this longstanding pattern of service use. Coexisting physical health conditions in older people with MH/SU conditions mean that they are often receiving care in general medical settings and are, therefore, familiar with and perhaps comfortable in these settings. Similarly, coexisting physical health conditions and cognitive and functional impairments mean that some older adults with MH/SU conditions are receiving care in general residential and home- and community-based settings. They are familiar with these settings, and many of them have physical and other difficulties getting to specialty MH/SU settings. Lack of knowledge about specialty mental health organizations and settings among older adults, their families, and even the medical, residential, and home- and community-based care providers who interact with them are probably also factors. People in the baby boom generation have had higher average rates of mental health service use throughout their lives, including use of specialty mental health services, and their willingness to use such services is expected to continue as they age. As a result, older adults’ use of specialty mental health services may increase in the future. At present, however, there is no clear consensus among geriatric MH/SU experts about which older people with MH/SU conditions would be better served in specialty versus general medical, residential, and home and community-based care settings. Moreover, concerns about whether the available MH/SU services are age-appropriate and culturally and linguistically appropriate pertain to both specialty and general care settings.

Box 2-7 describes older adults’ use of public mental health services provided by the public mental health system in San Diego County, California. The findings show low use of mental health services overall but high use of emergency psychiatric services provided by a mobile team of law enforcement and mental health personnel.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

BOX 2-7
Older Adults’ Use of Mental Health Services Provided by the San Diego County Public Mental Health System

The San Diego County public mental health system provides various specialty mental health services, including psychiatric hospitalization, emergency psychiatric unit, outpatient clinic, day treatment, and case management (Jin et al., 2003). A study of use of these services by adults with schizophrenia in 1999 and 2000 found that those age 65 and older were less likely than those under age 65 to use any of the services except case management. The researchers hypothesized that the older adults may have needed case management more than younger adults because of their coexisting medical conditions and functional impairments, and that as a service, case management may be more acceptable than the other services to older adults with schizophrenia.

Another study conducted in the San Diego county public mental health system from 2002 to 2006 found that adults age 60 and older were more likely than those under age 60 to enter the system through the Psychiatric Emergency Response Team (PERT), which responds to psychiatric-related 911 calls (Gilmer et al., 2009). Older adults were less likely than younger adults to use follow-up outpatient or inpatient mental health services in the next 90 days but more likely to have another encounter with the PERT. The researchers emphasize the need for better linkages between the PERT and outpatient mental health service providers to facilitate sustained follow-up care.

Trends in Older Adults’ Use of MH/SU Services

In recent years, the proportion and number of older adults receiving treatment for depression has increased substantially. Between 1992 and 1998, the proportion of community-living older adults with a diagnosis of depression that was receiving any treatment for the condition remained about the same, but the proportion that received only antidepressant medications increased, while the proportion that received only psychotherapy decreased (Crystal et al., 2003). This trend has continued, and in the period from 2002 to 2005, 67 percent of older adults with a diagnosis of depression received antidepressant medications, while only 15 percent received psychotherapy (Akincigil et al., 2011). In the period from 2005 to 2008, 15 percent of all community-living adults age 60 and over were taking

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

antidepressants, including 9 percent of men and 19 percent of women in that age group (Pratt et al., 2011).

The trends for increased use of antidepressants and decreased use of psychotherapy in older adults mirror changes that have taken place in treatment of depression in people of all ages (Marcus and Olfson, 2010; Olfson and Marcus, 2010) and have led some commentators to lament the reduction in potentially valuable treatment options (Akincigil et al., 2011; Druss, 2010). The high use of antidepressants in older people has likewise led to concerns about overuse, inappropriate use, and side effects (Hanlon et al., 2011; Mark et al., 2011). These concerns are increased by national data showing that among medical visits for people of all ages in which antidepressants were prescribed, the proportion in which there was no diagnosis of depression increased from 60 percent in 1996 to 73 percent in 2007 (Mojtabai and Olfson, 2011). Moreover, visits in which antidepressants were prescribed without a diagnosis of depression were significantly more frequent for people age 65 and older than for those under age 65.

Older African Americans with depression are less likely than older whites, Hispanic/Latinos, and Asian Americans to use antidepressants, thus raising concerns about possible underuse in this group. One study of more than 7,000 Medicaid beneficiaries age 65-84 with a diagnosis of depression found that in 1998, African Americans were significantly less likely than other groups to use antidepressants (Strothers et al., 2005). Another study that compared use of antidepressants by older people in five North Carolina counties in 1986 and 1996 found that use was lower for African Americans than whites in 1986 (2.3 percent versus 4.6 percent, respectively), and the difference between the groups increased over the next decade. In 1996, 5 percent of African Americans and 14 percent of whites were using antidepressants (Blazer et al., 2000a).

Aside from depression, it is not clear that treatment for other MH/SU conditions has increased in general for older adults. On the other hand, national data show that the use of antianxiety medications by community-living older adults increased from 8 percent in the period from 1999 to 2002 to 10 percent in the period from 2005 to 2008 (NCHS, 2011c). Use of antipsychotic medications for older people with dementia decreased from 1999 to 2007 (Kales et al., 2011), but concerns remain about overuse, inappropriate use and negative effects of all these medications, especially in older people who are taking multiple medications for other physical health conditions (McLendon and Shelton, 2012).

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

FACTORS THAT COULD AFFECT THE FUTURE
MH/SU SERVICE NEEDS OF OLDER ADULTS

U.S. Census Bureau projections show that the population age 65 and older will increase from 40.3 million in 2010 to 54.8 million in 2020 and 72.1 million in 2030 (Census Bureau, 2011b). As discussed earlier in this chapter, the committee estimates that at least 5.6 million to 8 million adults age 65 and older, or 14 percent to 20 percent of the older population, had one or more MH/SU conditions in 2010 (see Table 2-5). Even without future changes in the proportion of older adults with MH/SU conditions, projected growth in the older population will result in large increases in the number of older adults with these conditions. Applying the 14 percent to 20 percent figures to the projected population for 2020, 54.8 million older adults, indicates there will be at least 7.7 million to 11 million older adults with one or more MH/SU conditions in 2020. Applying the same figures to the projected population for 2030, 72.1 million older adults, indicates there will be at least 10.1 million to 14.4 million older adults with one or more MH/SU conditions in 2030.

These figures for 2020 and 2030 are conservative because the 2010 figures on which they are based include only 13 of the 27 MH/SU conditions identified by the committee. Data presented earlier in this chapter show that several million older adults may have one or more of three other conditions—depressive symptoms, anxiety symptoms, and at-risk drinking. These people are not included in the committee’s 2010 estimates, mainly because information is not available to account for comorbidity. The numbers for the other 11 conditions are smaller or not available, but adding people with any of the conditions that were not included in the committee’s estimates would increase the totals for 2010 and, in turn, the estimated proportions and numbers of older adults that will have MH/SU conditions in 2020 and 2030.

Large increases in future numbers of older adults with MH/SU conditions due to growth in the size of the older population will clearly create a need for more MH/SU services and a substantially larger workforce capable of providing the services. If, in addition to growth in the size of the older population, there are also increases in the proportion of older adults that has particular conditions, those increases would further expand the total number of older adults with the conditions and related service needs and workforce requirements.

In the past, population-based surveys of MH/SU conditions have found much higher rates for most MH/SU conditions in younger people than in older people. Table 2-13 illustrates this pattern. The table shows 12-month prevalence rates for 10 DSM-IV-TR mental disorders

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-13
12-Month Prevalence of Selected MH/SU Conditions in Community- Living People in the United States by Age Group

  Age Group
35-44
(%)
45-54
(%)
55-64
(%)
65-74
(%)
75+
(%)
Mental health conditions
Depressive
disorders
10.0 8.8 6.4 3.7 2.1
Major depressive episode 9.8 8.4 6.4 3.7 2.0
Dysthymic
disorder
2.9 3.5 2.1 0.9 0.7
Panic disorder 3.3 3.2 2.1 0.5 1.8
Agoraphobia without panic 1.0 1.3 0.8 0.4 0.2
Social phobia 8.2 7.0 5.2 3.6 1.1
Generalized anxiety disorder 4.7 4.8 4.2 1.8 1.3
Posttraumatic stress disorder 3.4 4.6 3.7 0.8 0.4
Substance use conditions
Alcohol dependence or abuse 3.0 1.9 0.7 a a
Other drug dependence or abuse 1.1 0.5 a a a
Summary figures
One or more of the disorders 20.4 19.8 14.1 8.2 4.8
Two or more of the disorders 9.4 8.4 5.8 2.5 1.8
Three or more of the disorders 4.7 4.3 3.3 0.8 0.5

a The prevalence rate from the CPES is less than 0.2 percent.

SOURCE: Center for Multicultural Mental Health Research, 2011.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

for community-living people in five age groups. The data come from the CPES conducted from 2001 to 2003 (see Box 2-2).

As shown in the table, rates for each disorder are higher in the groups under age 65 than in the groups age 65-74 and 75 and older. For each of the summary variables, the rates drop steadily from a high in people age 35-44 to a low in people age 75 and older.

Findings from other population-based surveys of MH/SU conditions that have included older adults, such as the ECA survey conducted in the early 1980s, and the NESARC 1, conducted from 2001 to 2002, show the same pattern of higher rates in younger people and a drop-off after age 65. One might expect that the higher rates in younger age groups, for example, the groups age 45-54 and 55-64, would be maintained as people in those age groups become age 65 and older. In fact, rates for some MH/SU conditions in adults age 65 and older have increased since the 1980s, but the increases have been smaller than would be expected if the higher rates in younger age groups had been maintained as they grew older.

The extent to which the pattern of higher rates in younger people and a drop-off after age 65 will be maintained in the future is unclear. A major factor in this context is the aging of the baby boomer cohort. This large cohort of individuals born between 1946 and 1964 was age 46 to 64 in 2010, and its oldest members turned 65 in 2011. Many researchers, clinicians, and others believe that prevalence rates for some MH/SU conditions, particularly alcohol-related and drug-related conditions, will rise substantially in the older population as the baby boomers age. The committee agrees that the prevalence of these conditions will increase in coming decades, but concludes that it is not possible at present to predict the rates or number of older adults who will have the conditions in 2020 or 2030.

Table 2-14 shows 12-month prevalence rates for self-reported alcohol-related and drug-related conditions in community-living adults age 65 and older at 2-year intervals from 2000 and 2010. The data come from the NSDUH.

As shown in the table, rates of alcohol-related conditions in older adults increased by small amounts from 2000 through 2010, with slight variations in the intervening years. Rates for three of the drug-related conditions also increased by small amounts over that period, and rates for drug dependence or abuse were the same in 2000 and 2010. Rates for nonmedical use of prescription pain relievers were not reported for 2000, but were the same in 2002 and 2010, with slight variations in the intervening years.

Tracking changes in age cohorts as they grow older is complicated. It is interesting to note, however, that in 2000, the self-reported rates for binge drinking were 15.8 percent in the group age 55-59 and 11.3 percent

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 2-14
12-Month Prevalence Rates for Alcohol- and Drug-Related Conditions in Adults Age 65 and Older in 2000, 2002, 2004, 2006, 2008, and 2010

Year
  2000 N = 2,946
(%)
2002 N = 2,239
(%)
2004 N = 2,393
(%)
2006 N = 2,665
(%)
2008 N = 2,527
(%)
2010 N = 2,500
(%)
Alcohol-related conditions
Binge alcohol use in the past montha 6.1 7.5 6.9 7.6 8.2 7.6
Heavy alcohol use in the past monthb 1.5 1.4 1.8 1.6 2.2 1.6
Alcohol dependence/abuse in the past yearc 1.4 1.2 1.4 1.3 1.0 2.0
Drug-related conditions
Illicit drug use in the past yeard 0.7 1.3 0.9 1.1 1.4 1.7
Marijuana use in the past month e 0.5 0.3 0.5 0.4 1.0
Nonmedical use of prescription drugs in the past year 0.6 0.7 0.6 0.6 0.9 0.9
Nonmedical use of prescription pain relievers in the past year f 0.4 0.4 0.5 0.8 0.4
Drug dependence/abuse in the past yearc 0.1 e e 0.1 0.2 0.1

a Binge alcohol use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

bHeavy alcohol use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days; all heavy alcohol users are also binge alcohol users

cSee Box 2-1 for definitions

dIllicit drugs are marijuana, cocaine, heroin, hallucinogens, inhalants, and prescription-type psychotherapeutic drugs, including pain relievers, that are used for nonmedical purposes.

e Numbers were not reported because of low precision

fNonmedical use of prescription pain relievers is not reported for the 2000 NSDUH

SOURCES: CBHSQ, 2012f; Center for Behavioral Health Statistics and Quality, unpublished data from the 2010 National Survey on Drug Use and Health provided to the IOM committee, 2011

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

in the group age 60-64. In 2010, when people in these groups were age 65-69 and 70-74, the self-reported rates for binge drinking were 11.0 percent in the group age 65-69 and 8.6 percent in the group age 70-74, compared with only 4 percent in the group age 75 and older. For nonmedical use of prescription drugs, the self-reported rates in 2000 were 2.5 percent in the group age 55-59 and 0.9 percent in the group age 60-64. In 2010, when people in these groups were age 65-69 and 70-74, the self-reported rates for nonmedical use of prescription drugs were 1.3 percent in the group age 65-69, 0.7 percent in the group age 70-74, and 0.7 percent in the group age 75 and older.

One research team has estimated the growth in the number of people with nonmedical use of prescription drugs from 1999 to 2020 for various age groups (Colliver et al., 2006). The researchers predict that the number of people with this condition in the group age 60-69 will increase more than fivefold, from 170,000 people in 1999 to 991,000 people in 2020. The comparable figures are 131,000 to 321,000 people in the group age 70-79 and 31,000 to 70,000 people in the group age 80-89.

Several recent reports on various aspects of illicit drug use also suggest future increases in the older population:

•   A 2009 report shows that use of illicit drugs almost doubled, from 5.1 to 9.4 percent, for adults age 50-59 in the period from 2002 and 2007 (Han et al., 2009). The researchers point out that nearly 90 percent of adults age 50-59 who were using illicit drugs in 2007 began using such drugs before age 30, suggesting that illicit drug use is a lifelong habit that is likely to continue as this age group gets older.

•   A 2011 report, based on data from the Drug Abuse Warning Network surveillance system, shows that 61 percent of the 1.1 million emergency department (ED) visits for adverse drug reactions in 2008 involved a person age 65 or older and nearly one-quarter of these ED visits were for adverse reactions to central nervous system drugs, including narcotic and nonnarcotic pain relievers (CBHSQ, 2011a).

•   A 2011 report on substance use treatment for adults age 55 and older found that the proportion of adults in that age group with first admissions for substance use treatment increased from 2.9 percent in 1998 to 4.4 percent in 2008 (Arndt et al., 2011). Admissions for alcohol treatment were more common than admissions for other drug treatment throughout the 10-year period, but admissions for treatment of marijuana, cocaine, and heroin abuse increased from 1998 to 2008.

•   A 2010 report on urine screens for drug use that were conducted in an academic suburban hospital shows that in the period from

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

2004 to 2009, 2.3 percent of screens for adults age 65 and older were positive for cocaine (Chait et al., 2010).

Another condition for which recent reports suggest possible increases in future prevalence rates in the older population is suicide. As discussed earlier in this section, reported suicide rates have been higher for white men age 85 and older than for any other group for at least the past 60 years, and suicide rates for white men age 75-84 have been second highest in that period (NCHS, 2011a). From 1999 to 2005, average annual suicide rates for whites of all ages increased by 1.1 percent, while average annual suicide rates for blacks decreased by 1.1 percent (Hu et al., 2008). Among whites, average annual suicide rates increased by 3 percent in those age 40-64 and decreased by 1.2 percent for those age 65 and older, and among whites age 40-64, the average annual increase in suicide rates was higher for women than men (3.9 percent versus 2.7 percent, respectively). For women in that age group, suicides by poisoning, including drug-related suicides, increased by an average annual rate of 19.3 percent.

Recent data also show a 49 percent increase in emergency department visits for drug-related suicide attempts in women age 50 and older between 2005 and 2009 (CBHSQ, 2011b). For women in this age group, statistically significant increases were found for ED visits for suicide attempts involving drugs used to treat anxiety and insomnia and some narcotic pain relievers.

In addition to increases in the number of older adults with MH/SU conditions that result from growth in the size of the older population and increases in prevalence rates for particular MH/SU conditions, another factor that will affect the future number of older adults with these conditions is changes in the age composition of the older population. As noted earlier in this chapter, 54 percent of the 40.3 million adults age 65 and older in 2010 were age 65-74, 32 percent were age 75-84, and 14 percent were age 85 and older (Census Bureau, 2011b). As the baby boomer cohort ages, the proportion of the older population that is age 65-74 is projected to increase to 59 percent in 2020 and return to 54 percent in 2030 (Census Bureau, 2011b). The proportion that is age 75-84 is projected to decrease to 29 percent in 2020 and then increase to 34 percent in 2030. The proportion that is age 85 and older is projected to decrease from 14 to 12 percent in 2020 and remain at that level until after 2031, when the oldest baby boomers begin to reach age 85.

Because the prevalence of dementia increases with age (Plassman et al., 2007), growth in the proportion of adults age 75-84 by 2030 is likely to result in larger numbers of older adults with dementia-related behavioral and psychiatric symptoms. It is unclear what, if any, other MH/SU conditions are more prevalent in adults age 75-84 than in those age 65-74

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

and would therefore increase disproportionately as the oldest baby boomers begin to reach age 75 in 2021.

Likewise, it is unclear what conditions other than suicide and dementia are more prevalent in adults age 85 and older than in those ages 65-74 and 75-84. As the total number of people in the oldest old age group grows from 5.5 million in 2010 to a projected 6.6 million in 2020 and 8.7 million in 2030 (Census Bureau, 2011b), the number with MH/SU conditions is likely to grow proportionately. For particular conditions with high prevalence in this age group, the numbers will likely grow even faster after 2031. More information is needed about the prevalence of particular MH/SU conditions in adults age 75-84 and 85 and older to plan for the services and workforce required to meet their service needs now and in the future.

Changes in the racial and ethnic composition of the older population will probably also affect the number of older adults with MH/SU conditions. From 2010 to 2030, the number of whites age 65 and older will increase by about 60 percent, but the proportion of whites in the older population will decrease from about 80 percent to about 71 percent. In the same period, the number of people in all other racial and ethnic groups will increase by larger proportions: the number of blacks will increase by about 115 percent, and the number of Hispanic/Latinos will increase by more than 200 percent. Blacks, Hispanic/Latinos, and other racial/ethnic groups will also increase as a proportion of the older population. In 2030, blacks will constitute about 10 percent of the older population, up from about 8.5 percent in 2010, and Hispanic/Latinos will constitute about 12 percent of the older population, up from 8 percent in 2010 (Census Bureau, 2008).

Analyses conducted for the committee by the Center for Multicultural Mental Health Research show that the prevalence of DSM-IV-TR mental disorders varies in different racial and ethnic groups. As shown previously (see Table 2-7), prevalence rates for some disorders and for one or more, two or more, and three or more disorders seems to be higher for older Hispanic/Latinos than for older adults in other groups, but these differences have not been tested for statistical significance. If it is true that prevalence rates are higher in the Hispanic/Latino group, the expected growth in the number of older Hispanic/Latinos from 2010 to 2030 will result in further increases in the total number and proportion of older adults with MH/SU conditions. As discussed earlier, various factors have been found to be related to the prevalence of MH/SU conditions in older adults in different racial and ethnic groups, for example, whether the person was born in the United States or elsewhere; how long the person has been in the United States; and the person’s gender, education, income, perceived financial strain, and life events. Epidemiologic research

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

is needed to clarify these relationships and their likely impact on future proportions and numbers of older adults with MH/SU conditions in racial and ethnic groups.

Lastly, for veterans who are enrolled in the VA health care system and use VA services, available data on the prevalence of some MH/SU conditions in younger age groups suggest large future increases in the number of veterans with these conditions. Table 2-15 shows the 12-month prevalence of selected MH/SU diagnoses in veterans who used VA health care services in FY 2011 for five age groups.

As shown in the table, the prevalence of each condition and one or more, two or more, and three or more conditions is higher in the groups under age 65 than in the groups ages 65-74 and 75 and older. The prevalence of diagnosed PTSD is very high in the groups ages 35-44 and 55-64. Prevalence rates for some other conditions, notably diagnosed alcohol-related and drug-related conditions, are higher in the group age 45-54. These data indicate that expanded VA services will be required in the future to the meet the needs of larger numbers of older veterans with MH/SU conditions in general, and workforce competencies to address particular conditions will have to be increased.

As noted earlier, people in the baby boom generation have had higher average rates of mental health service use throughout their lives, and their willingness to use such services is expected to continue as they age. No data are available to test this expectation now, but accurate and timely information about service use will be needed in the future for service and workforce planning.

TABLE 2-15
12-Month Prevalence of Selected MH/SU Diagnoses in Veterans Who Used VA Health Care Services in FY 2011 by Age Group

MH/SU
Diagnoses
Age Group
35-44 45-54 55-64 65-74 75+
Mental health diagnoses
Major depressive disorder 8.2 8.5 7.0 3.3 1.4
Dysthymic
disorder
2.5 2.9 2.8 1.7 1.1
Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×
Other mood
spectrum
disorders
18.0 18.8 16.7 9.7 6.9
Schizophrenia 1.7 3.1 2.4 1.0 0.5
Bipolar disorder 4.3 4.7 2.5 1.2 0.4
Other psychoses 1.0 1.4 1.1 0.6 0.9
Panic disorder 2.0 1.6 1.1 0.5 0.2
Agoraphobia without panic a a a a a
Social phobia 0.2 0.2 0.1 a a
Generalized anxiety disorder 2.3 2.1 1.8 1.1 0.8
Posttraumatic stress disorder 15.0 9.6 16.4 6.7 2.5
Substance use diagnoses
Alcohol
dependence or abuse
8.2 12.2 9.7 4.3 1.2
Other drug dependence or abuse 6.0 10.0 5.4 1.1 0.2
Summary figures
One or more of the diagnoses 35.5 37.8 37.5 20.6 12.2
Two or more of the diagnoses 19.3 20.5 18.2 7.4 2.9
Three or more of the diagnoses 8.9 10.1 7.5 2.4 0.7

a Proportion is less than 0.1 percent. SOURCE: VA, 2012.

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

SUMMARY OF FINDINGS AND IMPLICATIONS FOR
THE GERIATRIC MENTAL HEALTH WORKFORCE

Many older adults have MH/SU conditions. Analyses conducted for this IOM report indicate that in 2010, at least 5.6 million to 8 million adults age 65 and older had one or more of the 27 conditions identified by the committee as likely to have a substantial negative effect on the person’s emotional well-being, functional and self-care abilities, and quality of life. These figures represent 14 to 20 percent of the 40.3 million older adults in 2010. The figures constitute a conservative estimate of the number and proportion of older adults with MH/SU conditions for two reasons. First, they are based primarily on data from surveys conducted in nationally representative, population-based samples, and these surveys do not assess all the conditions identified by the committee. In addition, the figures include only older adults with conditions for which adequate information was available to avoid double counting people with more than one condition. As a result, the figures do not include large numbers of older adults with conditions for which information about comorbidity could not be found.

Accurate, up-to-date information about the number and proportion of older adults with MH/SU conditions is essential for analyzing their service needs and planning for a workforce capable of meeting those needs. Assembling the available information about the frequency of these conditions for this report was difficult. Some of the needed information existed but was not readily accessible, and much of the needed information was not available at all. More comprehensive information is essential to support planning for MH/SU services for older adults and related workforce requirements. Much of this planning occurs at the state and local levels, so the needed information includes not only national-level data, but also state- and local-level data.

The 27 MH/SU conditions identified by the committee include 15 conditions that are defined as mental disorders in the DSM-IV-TR. The other 12 conditions are symptoms or clusters of symptoms that are not defined as mental disorders in the DSM-IV-TR. In general, more information is available about the proportion and number of older adults with DSM-IV-TR-defined mental disorders, but the committee did not find data to support estimates of the number or proportion of older adults with two of the DSM-IV-TR mental disorders, and the accuracy of the available data on three other DSM-IV-TR conditions is unclear.

For the 5.6 million to 8 million adults age 65 and older with one or more MH/SU conditions, the most prevalent conditions were DSM-IV-TR depressive disorders and behavioral and psychiatric symptoms associated with dementia. The available data indicate that 1.8 million to 2.4 million

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

older adults had depressive disorders in 2010, and 2.2 million to 2.9 million older adults had behavioral and psychiatric symptoms associated with dementia. The numbers are smaller but still substantial for other conditions included in the totals, for example, social phobia and generalized anxiety disorder, each of which affects up to 800,000 or more older adults. The range of figures for these conditions is wide, however. The ranges for PTSD and alcohol dependence or abuse are even wider (200,000 to 1 million older adults for PTSD and less than 50,000 to 700,000 for alcohol dependence or abuse).

Several DSM-IV-TR mental disorders, including bipolar disorder and schizophrenia, constitute the core of a category of conditions, SMI, that create a high need for treatment, usually involving specialty mental health providers and services. The committee defined SMI to include those two conditions plus nonaffective psychoses and major depressive disorder that is not responsive to treatment. Based on this definition and information assembled for this report, the committee estimates that 1.4 million to 1.9 million older adults had SMI in 2010. These figures represent 3 to 4.8 percent of the older population.

Large proportions of older adults who have MH/SU conditions also have coexisting acute and chronic physical health conditions, and some have cognitive and functional impairments. These coexisting conditions are a defining feature of the geriatric mental health and substance use fields. They often complicate the detection, diagnosis, treatment, and ongoing management of MH/SU conditions; they also result in difficult caregiving situations for families, physicians, and other health care professionals, and residential care and home- and community-based service providers; and they may affect the types of MH/SU treatments and other services that are likely to work best and the care settings where these treatments and services should be delivered. Certainly they create important requirements for workforce competencies, including ability to detect possible MH/SU conditions in older adults with coexisting physical health conditions and cognitive and functional impairments; ability to diagnosis the conditions or knowledge about how to refer the person for a diagnostic evaluation; and ability to adapt treatments and ongoing management to accommodate the coexisting conditions.

A substantial proportion of older adults with MH/SU conditions live in nursing homes and other congregate-living settings, such as assisted living, senior housing, and public housing facilities. Practical and effective approaches for delivering MH/SU services differ for older adults in congregate-living settings versus older adults in single-family housing in the community, but the needed skills and competencies for staff working with older adults with MH/SU conditions in various kinds of congregate-living settings are similar. The development of a workforce with these

Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

skills and competencies is a high priority for improving care for older adults with MH/SU conditions.

Race and ethnicity are associated not only with likely differences in the prevalence of MH/SU conditions, but also with the kinds of treatment and services that are needed and will be used. As the racial and ethnic diversity of the older population increases, the need for diversity training and language competencies will also increase. MH/SU assessment procedures and service models will have to be adapted to meet the needs of the wide array of racial and ethnic subgroups.

Finally, it is clear that older veterans, at least those who are enrolled in the VA health care system and use VA health care services, are more likely than other older adults to have MH/SU conditions and to have particular conditions that influence their service needs. Workforce competencies within the VA health care system and awareness among non-VA health care professionals and service providers of referral procedures for veterans who will benefit from VA MH/SU services are essential to meet the needs of these veterans.

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Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

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Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Suggested Citation:"2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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At least 5.6 million to 8 million--nearly one in five--older adults in America have one or more mental health and substance use conditions, which present unique challenges for their care. With the number of adults age 65 and older projected to soar from 40.3 million in 2010 to 72.1 million by 2030, the aging of America holds profound consequences for the nation.

For decades, policymakers have been warned that the nation's health care workforce is ill-equipped to care for a rapidly growing and increasingly diverse population. In the specific disciplines of mental health and substance use, there have been similar warnings about serious workforce shortages, insufficient workforce diversity, and lack of basic competence and core knowledge in key areas.

Following its 2008 report highlighting the urgency of expanding and strengthening the geriatric health care workforce, the IOM was asked by the Department of Health and Human Services to undertake a complementary study on the geriatric mental health and substance use workforce. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? assesses the needs of this population and the workforce that serves it. The breadth and magnitude of inadequate workforce training and personnel shortages have grown to such proportions, says the committee, that no single approach, nor a few isolated changes in disparate federal agencies or programs, can adequately address the issue. Overcoming these challenges will require focused and coordinated action by all.

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